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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 382 | APPLING NURSING AND REHABILITATION PAVILION | 115262 | 163 EAST TOLLISON STREET | BAXLEY | GA | 31513 | 2018-07-12 | 761 | D | 0 | 1 | 802511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. 07/11/18 an observation on C Hall Licensed Practical Nurse (LPN) GG at 7:56 a.m. LPN GG was observed to walk down the C hall towards the rotunda and administer medications to a resident in the hall way leaving stock medications on top of the medication cart and his back was to the cart. At 7:58 a.m. LPN GG was observed to go into room [ROOM NUMBER] and left the same medication on top of the medication cart, unsupervised with stock medications in closed bottles, on top of the medication cart (no observed residents on hall). Further observation revealed that LPN GG was in room [ROOM NUMBER] approximately 3 minutes before returning to the unsupervised cart, the cart was parked outside of the room and to the right on the wall, not in view of LPN G[NAME] On 07/11/18 at 8:13 a.m. Interview with LPN GG reported that medications should not be left on top of the medication unsupervised. 07/12/18 10:10 AM Interview with LPN Nurse Manager AA on A hall reported that it is not acceptable to leave medications on the top of the med cart out of view. Also stated that she educates nurses on policies and procedures. In continued interview with nurse manager AA revealed that nurses receive orientation on hire and also the Director of Nurses (DON) does in-service education on needed areas of concern or skills that need addressed. 7/12/18 10:37 a.m. Interview with the DON revealed that she expects the nurses to lock all medications in the medication cart when they are not by their cart and follow the medication administration policy. 7/12/18 11:19 a.m. Interview with the Assistant Director of Nursing (ADON) reported that licensed practical nurse GG received education related not leaving medication on the cart unsupervised. The ADON provided education material signed and dated on 4/27/17 and 5/15/18; Medication Pass Guidelines. Review of the A monthly pharmacy Medication Pass Guidelines, dated 6/18/18; 1. Medication Cart and Drug Security; c. Appropriate drug security maintained; cart always visible to the nurse or is locked. Based on observation, policy review and staff interviews the facility failed to remove expired medications by the expiration date in two out of three medication (med) storage rooms and failed to keep medications in locked medication cart during medication administration. The facility census was 101 residents. Findings included: 1. Observation on 7/11/18 at 3:00 p.m. of the C Hall Medication (med) storage room, with the Registered Nurse (RN) Unit Manager JJ, and a surveyor-trainee, revealed (12) expired medications. Inside a mini-refrigerator in the med storage room, a small emergency med box (e-box) contained emergency meds that needed to be refrigerated. The label on the outside of the e-box had expiration date 6/2018, two (2) [MEDICATION NAME] ([MEDICATION NAME]) suppositories inside the e-box had expiration date 6/2018 on each individual suppository package. Further Observation of C Hall med storage room & mini refrigerator also revealed a box of ten (10) [MEDICATION NAME] Quadrivalent (Influenza Vaccine) prefilled syringes. The expiration date on the box and on the ten (10) individual syringes were 6/12/18. Interview at that time with the RN Unit Manager JJ, and the surveyor-trainee, confirmed (12) medications were expired. Observation on 7/11/18 at 3:25 p.m. of the B Hall med storage room with Licensed Practical Nurse (LPN) KK, and a surveyor-trainee, revealed two (2) expired medications inside a mini-refrigerator in the small med e-box. The label on the e-box had expiration date 6/2018 and inside were two (2) [MEDICATION NAME] ([MEDICATION NAME]) suppositories with the expiration date 6/2018 on each individual suppository package. Interview at that time with LPN KK, and the surveyor-trainee, confirmed the meds were expired. Observation on 7/11/18 at 3:50 p.m. of the A Hall med storage room & mini-refrigerator with LPN Nurse Manager AA, and a surveyor-trainee, revealed no expired medications. Observation on 7/11/18 at 5:00 p.m. of three medication carts, from A, B & C Hall, revealed no issues with storage or labeling, and no expired meds. On 7/12/18 review of the Medication Storage policy revealed medication rooms are routinely inspected by the DON, Assistant Director of Nursing (ADON), or nurse managers, for discontinued and outdated meds. Discontinued and outdated narcotics are kept locked until picked up for destruction. Discontinued and outdated non-narcotic meds are logged and stored in designated area until picked up by pharmacy for destruction. Interview on 7/12/18 at 12:00 p.m. with the ADON revealed all nurses are responsible for dating meds when opened & monitoring for expired, & discontinued meds. All med storage rooms are inspected monthly by the hall nurse with follow up by the nurse manager or the ADON. During medication room inspection any outdated meds are pulled, logged and stored in the ADON office. A Medication check-off inspection form is completed every month for all med storage rooms, signed by hall nurse and nurse manager or ADON and kept in the Pharmacy (monthly review) notebook. Continued interview revealed nurses are educated on med administration, labeling, storage and monitoring for expiration dates during new hire training and periodically. The ADON revealed she does facility education and will review with nursing staff what to do if they find a medication that will soon expire, the importance of removing it by the last day, or either go ahead and pull it so it won't get missed. She also revealed she will start putting med expiration dates on a calendar on her computer that will send her a reminder alert. Interview on 7/12/18 at 12:15 p.m. the with the DON and Minimum Data Set (MDS) Coordinator LL revealed every hall nurse is responsible for monitoring for expired medications & supplies all the time. A monthly inspection is done on all med storage rooms, the nurse manager, ADON, & DON follows up, a inspection form titled Medication Area checklist is completed and signed by both. The completed inspection forms are kept in the Pharmacy (monthly review) notebook. Expired non-narcotic meds are pulled, logged, and put in a bin in the ADON office until the pharmacy picks them up, monthly. The DON said her expectation would be, if the check was done on 6/18 and meds were expiring the last day of June, staff go ahead and pull the medication so it won't get missed and left beyond the expiration date. Review of the Pharmacy notebook revealed the Medication Area checklist inspection forms had been completed for (MONTH) through (MONTH) (YEAR), with two signatures and no issues. The inspection form for (MONTH) (YEAR) revealed B Hall and C Hall med storage rooms were inspected on 6/18/18 with no out of date meds found and were signed by the hall nurse & ADON. | 2020-09-01 |
| 6412 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2014-06-25 | 441 | E | 0 | 1 | OWMB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 6/23/14 at 7:44 a.m. and 1:00 p.m., on 6/24/14 at 10:35 a.m. and on 6/25/14 at 7:45 a.m., there were two (2) bedpans and two (2) bath basins on the shelf above the toilet in the adjoining bathroom for rooms [ROOM NUMBERS] on the B Hall. Staff had failed to label the bedpans and basins with the residents' names and failed to appropriately store the bedpans and basins in bags to prevent cross contamination. One (1) of the bedpans had dried fecal material inside the bowl. Observation on 6/23/14 at 7:51 a.m., on 6/25/14 at 12:32 p.m. and on 6/25/14 at 7:50 a.m., there was one (1) bedpan and three (3) bath basins on the shelf above the toilet in the adjoining bathroom for rooms [ROOM NUMBERS] on the B Hall. Staff had failed to appropriately store the bedpan and bath basins in bags to prevent cross contamination. An interview with the Licensed Practical Nurse (LPN) AA, the infection control nurse on 6/25/14 at 8:05 a.m. revealed that the residents' bath basins and bedpans were suppose to be washed completely after use, labeled with the resident's name, stored in a plastic bag and placed in the resident's bathroom on the shelf above the toilet. Observation and interview on 6/25/14 at 8:10 a.m. with LPN AA confirmed that staff failed to appropriately clean and store the residents' bedpans and bath basins in the adjoining bathrooms for rooms 203, 204, 205 and 206. Based on observations, staff interviews and handwashing policy review, facility failed to ensure that staff maintained proper handwashing between resident contact during dining observation to prevent possible cross contamination on two (2) of three (3) halls. Also, facility failed to ensure that personal care items were labeled and stored to prevent possible cross contamination on one (1) of three (3) halls. Findings include: 1.) During the dinner dining observation on the C-hall between 5:35 p.m.-6:00 p.m. on 6/22/14, revealed a Certified Nursing Assistant (CNA) took a tray into room C-4A, set up the dinner tray, then went into room C-2A, without washing her hands and touched the resident's linens, then touched the resident's hair. Continued observation revealed that this same CNA went to get the nurse for room C-2A, and then proceeded to go back into room C-2A, which at this time she washed her hands. This particular CNA went to room C-4B, set up resident's dinner tray after touching bed, linens, and overbed table, all without washing her hands, and then the CNA went onto room C-5A and set up this resident's dinner tray, all without washing her hands. Also, while she was in room C-5A, she raised the head of the bed and put the resident's glasses on her face, then went back to the tray cart out in the hallway and touched two (2) trays, still without washing her hands. Continued observation revealed that this CNA went onto room C-9B, raised the head of the bed, set up tray and then washed her hands. She then went onto room C-11B where she moved a plastic bag from the overbed table to place the resident's dinner tray, then she went back to the tray cart, and moved onto room C-12B moving around various items on the overbed table, such as the Kleenex box, and the remote control. She then set up the resident's dinner tray and washed hands, so that she could feed the resident. Interview with the Director of Nursing (DON) on 6/24/14 at 12:15 p.m., revealed that she expected staff to wash their hands between resident contact using soap and water, and before returning to the tray cart. Review of the Handwashing Policy and Procedure revealed that all personnel shall wash their hands to prevent the spread of infections and diseases to other residents, personnel, and visitors. Continued review revealed that appropriate handwashing must be performed under the following conditions before touching, preparing or serving food, and after having prolonged contact with a resident (i.e., bedbath, changing linen, etc.). Review of the Inservice Education Program Attendance Sheet dated 4/23/14 revealed that staff were inserviced on handwashing. | 2018-01-01 |
| 6534 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2014-02-27 | 333 | D | 0 | 1 | 23LW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #59 had [DIAGNOSES REDACTED]. There was a care plan in place since 11/4/13 for the use of [MEDICAL CONDITION] medications related to [MEDICAL CONDITION]. The care plan included an intervention for nurses to administer medications as ordered. There was a physician's orders [REDACTED]. However, a review of the January 2014 and February 2014 Medication Administration Record [REDACTED]. The dispensing pharmacy confirmed the medication error during an interview on 2/27/14 at 2:22 p.m. Based on observation, record review and staff interviews the facility failed to ensure that a medications, with potential serious side effects, is given as order by the physician for two (2) residents (#59 and 149) by two (2) nurses of five (5). Findings include: 1. Record review of the physician orders [REDACTED].m During observation of medication administration on 2/27/14 at 9:14 a.m. with Licensed Practical Nurse (LPN) AA revealed that the resident was given [MEDICATION NAME] 1 mg at this time. Review of the MAR indicated [REDACTED]. An interview with LPN AA at 9:33 a.m. revealed that she thought the medication administration time had been changed but she was confused. She did not realize she had given the [MEDICATION NAME] 1 mg although confirmed that the night nurse had signed off as giving the medication at 6:00 a.m. and the resident had received another dose. She revealed that the physician should be contacted and it should be determined if the resident can go on the scheduled trip out of the facility this morning. An interview with the Administrator on the same day at 10:01 a.m. revealed she had called the resident's physician who ordered to monitor the resident's blood pressure before and during the field trip. | 2017-12-01 |
| 8824 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2015-08-12 | 278 | D | 1 | 0 | I93Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #04 was admitted to the facility in January 2014 was a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed no antipsychotic medications in Section N. Review of the August 2015 Physician order [REDACTED]. Review of the October 2014 and November 2014 Medication Administration Record [REDACTED]. Interview with the MDS Coordinator AA on 8/11/15 at 12:48 p.m., revealed that the coding on this particular MDS was incorrect and stated that she gets her information from the diagnosis, and medication in Point Click Care (PCC). Based on record review and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the assessment of two (2) residents (#01 and #04) regarding pressure sores, and anti-psychotic medication from a total sample of ten (10). Findings include: 1). Resident #01 was admitted to the facility in January 2014 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed that Section M: Skin Conditions had no evidence of any unhealed pressure ulcers at Stage one (1) or higher. Review of the Wound Care: Weekly Wound Assessment/Condition Report (Pressure and Non-Pressure) dated 7/03/2015 revealed a Suspected Deep Tissue Injury (SDTI) to the right heel, which was first observed on 6/30/15. Review of the Wound Care: Weekly Wound Assessment/Condition Report (Pressure and Non-Pressure) dated 7/30/15 revealed a Stage two (2) to the left heel, which was first observed on 6/30/15. Interview with the Treatment Nurse GG and the MDS Coordinator AA on 8/11/2015 at 1:00 p.m., revealed that the MDS was miscoded regarding the pressure sores. Continued interview revealed that the right heel was a reddened area and the left heel had an unstageable deep tissue injury due to slough in the wound bed at the time of assessment. | 2015-10-01 |
| 2814 | WESTWOOD HEALTHCARE AND REHABILITATION | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2017-12-21 | 657 | D | 1 | 1 | 9VJ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 2. R#183 (a closed record) was admitted in 10/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status Score (BIMS) of 15 indicating she was alert and oriented; had trouble falling/staying asleep; rejected care daily; required limited assistance from one staff person for most activities of daily living (adls); was non-ambulatory; was on a scheduled pain medication regimen; and received antianxiety, antidepressant, and opioid medications daily. Review of the care plan dated 2/4/17 revealed that the resident was very independent with decision making and that the only behavior the resident exhibited was resistance to care at times including ADL care, wound treatments and medications. Review of the Admissions Packet revealed that the facility was a smoke free facility at the time of R#183's admission. Continued review revealed that items not allowed in a resident's room included cigarette lighters due to fire safety regulations. R#183 signed the Admissions Packet on 10/31/16 indicating that she would comply with all facility policies, procedures and regulations relating to the health, safety and welfare of all residents, staff and visitors including the smoking policy. Review of the Interdisciplinary Progress Note (IDPN) dated 12/22/16 revealed that R#183 was noted smoking on the activity patio. Staff re-educated the resident at that time that the facility had a smoke free policy and the resident voiced her understanding. Review of the Investigation Summary dated 12/30/16 sent to the State Agency (SA) revealed that on 12/28/16, the previous Treatment Nurse and Unit Manager (UM) were preparing R#183 for a shower and wound care. R#183 requested the UM to place her cell phone in her purse at that time. When the UM placed the cell phone in the resident's purse, she noted a pack of cigarettes and a lighter inside the purse. The previous Director of Nursing (DON) and previous Social Services Director (SSD) were notified and the resident was re-educated on the facility's no smoking policy. After receiving permission from the resident to search her room and personal belongings, one pack of cigarettes, two lighters, two electronic cigarettes, two electronic cigarette refill cartridges, three small bags with a white residue and one plastic straw were found. In addition, two [MEDICATION NAME] tablets (an antianxiety) and 19- 15 milligram (mg) [MEDICATION NAME] (an opioid), prescribed medications for the resident, were found. The local police were contacted and interviewed the resident; however, the resident refused to say who brought items from outside the facility. Staff disposed of all the found items and notified the resident's physician and family member. Continued review of the summary revealed that staff suspected that the resident was hoarding her medications to trade for illicit drugs. Interventions implemented by the facility to prevent further occurrences included a room check every 24 hours for five days with subsequent random room checks, physician's orders [REDACTED]. Review of the Nurses' Note dated 2/23/17 at 3:15 a.m. revealed that R#183 was observed smoking on the back porch. The resident was re-educated by staff about the facility's no smoking policy and stated that she would not do it again. Although R#183 was observed smoking against facility policy on 12/22/16 and 2/23/17 and was found with smoking supplies, hoarding medications and in the possession of possible illicit drugs on 12/28/16, staff failed to revise the resident's care plans dated 2/4/17, 5/7/17 and 8/7/17 to address those specific non-compliant unsafe behaviors. Review of the Incident/Accident Report dated 10/27/17 at 1:30 p.m. revealed that the Hospice Nurse found R#183 in her room possibly rolling a joint (marijuana cigarette). The SSD was called and staff searched the resident's room. Continued review revealed that several syringes and a spoon with a dried yellow substance were found. The local police were notified and inspected the drug paraphernalia found. The police believed that R#183 was pocketing her prescribed [MEDICATION NAME] (a pain medication) in her mouth and after the nurse left her room, crushed the medication, mixed it with water and injected it. Interventions implemented by staff at that time included unannounced room checks by staff, nurses had to check her mouth after medication administration to ensure she had swallowed her medications and she was educated that she would receive an immediate 30 day discharge notice if any drug paraphernalia was found on her person or in her room again. The physician was notified and ordered the [MEDICATION NAME] to be changed to liquid form. Review of the care plan dated 11/7/17 revealed that the resident was not swallowing her pain medications with an intervention for liquid medications as ordered. However, staff failed to revise the care plan to address the resident's non-compliance with the facility's smoking policy or having illicit drug paraphernalia (syringes and spoon) on her person or in her room. Review of the Nurses' Note dated 11/13/17 at 8:30 p.m. revealed that R#183 was observed outside smoking. Staff re-educated the resident again about the facility's smoking policy. Review of the Nurses' Notes dated 11/15/17 revealed that the resident admitted to staff that she had done meth. Continued review revealed that due to her erratic behaviors and admission of using illicit drugs, R#183 was discharged to a hospital by her physician because she was a danger to herself and others. Interview with the Administrator on 12/20/17 at 1:45 p.m. revealed that to her knowledge R#183 was never found smoking in her room and that there were no reports from staff or other residents of smelling cigarettes inside the facility. Continued interview revealed that staff did not observe the resident smoking on 12/28/16 although smoking supplies were found in her room that day. Further interview revealed that if the resident was observed smoking on 12/28/16 she would have been given a 30 day discharge notice per facility policy since it would have been her third occurrence. Interview with the MDS Coordinator on 12/21/17 at 11:00 a.m. revealed that there really is no reason that she failed to revise the resident's care plan for her non-compliance with the smoking policy and having medications and drug paraphernalia in her room. Based on observations, record reviews, and staff interviews, the facility failed to revise the care plans to address the non-compliance with the smoking policy, hoarding medications and having drug paraphernalia in her room for one resident (#183) from 16 residents reviewed. The census was 35 residents. | 2020-09-01 |
| 999 | LAGRANGE HEALTH AND REHAB | 115354 | 2111 WEST POINT ROAD | LAGRANGE | GA | 30240 | 2018-12-18 | 609 | D | 1 | 0 | TXXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Complainant and staff interviews, and review of the Grievance Log, the facility failed to initiate an investigation of an allegation of missing narcotics for one (1) resident (R#2) from a sample of eight (8) residents. Findings include: Interview on 12/18/18 at 10:50 a.m. with the East Unit Manager EE revealed that a family thought that they had brought medication but home to the facility; but, they had not brought any medication. She revealed that the resident was a Hospice resident from the Hospital and no medications were brought with the resident from the hospital. She revealed that she did not report the allegation because she never received any medication. She revealed that she should have filed this information on a complaint allegation form. Interview on 12/18/18 at 11:55 a.m. with the Complainant revealed that a family member of the resident was concerned about the resident's [MEDICATION NAME]. He revealed that a family member stated that a blister pack of [MEDICATION NAME] was stuck in a Bible although when she checked the Bible the pills were missing. He revealed that the family member had reported the missing narcotic to the staff and that the staff did not do anything about it. Interview on 12/18/18 at 12:55 p.m. with LPN FF revealed that the resident's family member had call her into the room and revealed that the family member had placed a card of medication in a book and it is now missing. She revealed that she referred the family member to the Director of Nursing (DON). She revealed that this was reported to her supervisor immediately. She revealed that she did not fill out a complaint investigation form for the missing medication. Interview on 12/18/18 at 1:10 p.m. with the DON revealed that she talked to the family member, who had a several complaints, although she was never informed of any missing narcotics. She revealed that an investigation was never completed on allegation of missing medication. She revealed that there is not policy of what to do with medications brought into the facility nor the use of the inventory sheet. She revealed that she was not aware of the allegation of the missing medications but that an investigation should have been initiated for the allegation of a missing narcotics. Review of the Grievance Log dated 10/2018, 11/2018, and 12/2018 indicated no investigations about missing medications. Review of the Abuse Policy indicated each resident has the right to be free from abuse, neglect, misappropriation of resident's property. Policy Explanation and Compliance Guidelines indicated that: 1. staff should report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, other Officials in accordance with State Law, State Survey and Certification agency through established procedures. 9. Response and Reporting of Abuse, Neglect and Exploitation- Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: (c.) Initiate an investigation immediately, (e) Obtain witness statements, following appropriate policies, (f.) contact the State Agency and local Ombudsman office to report the alleged abuse. | 2020-09-01 |
| 4140 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2017-03-24 | 166 | D | 1 | 0 | BIP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Complainant and staff interviews, and the Grievance Log the facility failed to ensure follow-up of a grievance of one (1) resident (R#4) of a feeling of neglect from a sample of twelve residents. Findings include: Interview on 3/20/17 at 12:30 pm with the Complainant revealed that (R#4) no longer wants to be in the facility. She revealed that the staff would not always answer the call light. She revealed that on the day that she was sent out to the Emergency Rood (ER), (January 2, (YEAR)), the Certified Nurse Assistant (CNA) did not provide care for her. She revealed that the staff did not change (R#4) when she was first admitted . She revealed that the (R#4) was wet with brown rings in her bed, (R#4) was wet from shoulder to toes on the next day. This was shown to the Nurse and Certified Nursing Assistant (CNA). The resident was discharged to an acute care hospital on [DATE] and was admitted to another facility when discharged from the hospital. Interview on 3/21/17 at 7:00 pm with the Administrator revealed that she had no conversations with the Complainant about any allegations. Interview on 3/22/17 at 1:08 pm with Licensed Practical Nurse (LPN) DD revealed that (R#4) talked about she was worried that there was not enough staff to to assist with her care. She revealed that (R#4) also stated that she felt like the Certified Nurse Assistants (CNA's) were not paying her any attention because of her size. She revealed that the (R#4) reported that she felt uncomfortable with the staff. Interview on 3/26/17 at 1:00 pm with the Complainant revealed that she had made several phone calls to the Administrator with no response to her concerns. She revealed that there was an on going problem at the facility that was never resolved. Review of the Grievance Log dated 8/31/16 indicated a grievance filed concerning (R#4) was wet from urine from shoulders to feet. Further review of Grievance log dated on 12/13/16 indicted (R#4) left wet from 0600 until 1600 with no evidence that the residents concern of discomfort , and neglect was addressed or followed up until after 3/24/2017. | 2020-03-01 |
| 2799 | PRUITTHEALTH - LANIER | 115600 | 2451 PEACHTREE INDUSTRIAL BLVD | BUFORD | GA | 30518 | 2017-05-11 | 281 | G | 1 | 0 | LD2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, family and staff interviews and review of the State of Georgia Rule 410-10.02 Standard of Practice for Licensed Practical Nurses (LPN) the facility failed to maintain professional nursing standards of quality as evidenced by not ensuring that enteral feeding and water flushes where documented or given to one resident (R A) who was hospitalized with urinary tract infection, severe dehydration, electrolyte imbalance, acute [MEDICAL CONDITION] and pneumonia. The sample size was three and the census was 92. Findings include: Review of the State of Georgia Rule 410-10-02 Standards of Practice for Licensed Practical Nurses (LPN) 1. The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: d) Administering treatments and medications by various routes 3. Documentation a) Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to a patient. Review of R A clinical record, revealed the resident was admitted to the facility on [DATE] after a hospital stay for a stroke with left side [MEDICAL CONDITION] and dysphagia. The resident has a history of [MEDICAL CONDITION] Fibrillation (AFib), [MEDICAL CONDITIONS], Type 2 diabetes, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION] and obesity. The resident was admitted to the facility with a Gastric Feeding tube (GT). Review of resident's Physician orders [REDACTED]. Flush tube before and after feeding with 20 ml of water. Administer 200 ml of water flushes every six hours. Review of the Nutritional Screening and Assessment Form dated 4/21/17 revealed the resident was assessed by the Registered Dietitian who felt the enteral feeding orders met the resident's nutritional and hydration needs. Glucerna 1.5 350 ml, via bolus gravity route, four times per day equaled 1400 ml, 200 ml water flushes every six hours equaled 800 ml per day and 20 ml before and after Glucerna equaled 160 ml for a daily total of 2360 ml per day. Review of the Medication Administration Record [REDACTED].m Review of the MAR for 20 ml of water before and after the Glucerna 1.5 revealed that on the following days and time there was no evidence that the water was given via bolus gravity route: 4/22/17 at 4:30 p.m., 4/23/17 at 4:30 p.m., 4/26/17 at 11:30 a.m. and 8:30 p.m., 4/27/17 and 4/28/17 at 7:30 a.m., 11:30 a.m. and 4:30 p.m Review of the MAR for the 200 ml water flush revealed that on the following days and time there was no evidence that the water flushes were given via bolus gravity route: 4/23/17 at 12:00 a.m., 4/24/17 at 6:00 a.m. and 12:00 a.m., 4/25/17 at 12:00 a.m., 4/26/17 at 12:00 p.m., 4/27/17 at 6:00 a.m., 12:00 p.m. and 12:00 a.m., on 4/28/17 at 12:00 p.m. An interview with LPN BB on 5/5/17 at 6:14 p.m. who, per the Director of Nursing (DON), had taken care of the resident several days. LPN BB confirmed her initials on the MAR for 4/25/17 and 4/26/17. When ask about the missing signatures, during the time that she was assigned, she revealed that she couldn't explain it but would think she gave either the bolus feeding or the water flush but could not confirm. She realizes it is her responsibility to sign off whenever a treatment or medication is given. An interview on 5/5/17 at 6:01 p.m. with the Administrator and the DON revealed they had both started in (YEAR). The DON provided the minutes for a Nurses Meeting dated 2/23/17 which documents that she had recognized that there were holes the MARs for insulin and vital signs with a signature sheet for this meeting. Registered Nurse (RN) AA and LPN CC had signed in for this meeting. The DON says that all treatments and medications should be given and signed off as given by the nurses. She agrees that there are multiple dates and times without a signature for the enteral feeding and water flushes for this resident. The DON did not provide how this was being monitored or how often. The DON revealed that the nurse working on the 3-11 p.m. shift on 4/28/17 was not available. Cross refer to 327 | 2020-09-01 |
| 4760 | COUNTRYSIDE HEALTH CENTER | 115592 | 233 CARROLLTON STREET | BUCHANAN | GA | 30113 | 2016-07-13 | 425 | D | 1 | 0 | JZ1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, faxed record review, review of Nursing 2014 Drug Handbook, review of Omnicare Longterm Care (LTC) Facility Pharmacy Services and Procedures manual, staff interview, pharmacist interview and physician interview the facility failed to provide Pharmaceutical Services to request clarification of an order for [REDACTED]. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the front of the chart binder, the face sheet, the (MONTH) Medication Administration Record [REDACTED]. Continued Review of the POS [REDACTED]. Review of the MAR for Resident #2 revealed she had received Ceftin 500 mg bid from 6/16/16 through 6/23/16 for fourteen (14) doses. Review of the Nurses 2014 Drug Handbook revealed on page 298 that Ceftin (Cefuroxime Axetil) is a second generation Cephalosporin. Review of page 300 revealed Ceftin is contraindicated for patients who are Hypersensitive to other Cephalosporin antibiotics. Review of Omnicare Longterm Care (LTC) Facility Pharmacy Services and Procedures Manual page 77, revealed the facility should ensure all resident information is complete and accurate, has been reconciled and is verified with the Physician/ Prescriber before faxing or transmitting orders to pharmacy. Additional review revealed the pharmacy may contact the facility by fax or phone before dispensing a medication when the pharmacist believes there is a need to clarify the medication order because the order is contraindicated. Review of facility faxed records file for 6/16/16 revealed no requests for clarification were received by the facility regarding the order for Ceftin for Resident #2. Review of facility copy of Omnicare shipment invoice dated 6/16/16 indicated Ceftin for Resident #2 was delivered to the facility at 10:30 p.m. Interview 7/13/16 at 9:45 a.m. with the Director of Nurses (DON) revealed the pharmacy is not supposed to send any medication that is contraindicated until a clarification order has been received from the facility. The pharmacy should not have dispensed the Ceftin for Resident #2 because it is contraindicated due to her allergy to other Cephalosporins, until a clarification order was received. The DON acknowledged there is no evidence of an alert, or request for clarification mentioned in the Nurses Notes or in the facility daily fax file, in the medication room, where all faxes received from the pharmacy are stored. The DON revealed the nurse who wrote the verbal order for Ceftin for Resident #2 is no longer employed by the facility and multiple attempts to reach her by phone have been unsuccessful. An additional nurse who administered this medication from 6/16/16 through 6/23/16 is also not employed by the facility, and her contact number is not in service. Interview 7/13/16 at 10:35 a.m. with the PCP for Resident #2 revealed he had not received any request for clarification of the Ceftin order for Resident #2 on 6/16/16 through 6/23/16. The physician confirmed if the pharmacy had requested clarification by phone or fax prior to sending the medication he would have received a call to request clarification and an additional order would have been written. Interview 7/13/16 at 11:37 a.m. with Omnicare supervising pharmacist revealed the standard procedure when an order is received for a contraindicated medication such as Ceftin, for a resident with other Cephalosporin allergies [REDACTED]. There is no documentation in the pharmacy computer to indicate a clarification was received prior to dispensing this medication. The supervising pharmacist confirmed there should be documentation of a clarification order before sending the Ceftin and would check with the pharmacist that dispensed the medication and call back. No return call was received. Cross Refer to F 281 and F 333 for additional details. | 2019-07-01 |
| 4690 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 280 | D | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, observations and staff interviews, the facility failed to revise the care plan for one resident (R5) out of 9 sampled residents. Findings include: R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During all days of the complaint investigation, the resident was observed in her wheelchair and moved throughout the facility. The resident was not observed with a cup of water in her hand. Review of R5's care plan dated 4/29/16 revealed that the resident was identified to be at risk for falls. A review of the Nurse's Notes dated 7/14/16, documented that the resident was observed out of bed ambulating and drinking 2 to 3 liters of water per hour. Per Nurse's Notes the physician was aware. On 7/21/16, the resident sustained [REDACTED]. An interview was conducted with the Director of Health Services (DHS) and the Corporate Nurse on 8/19/16 at 9:20 a.m. Per the DHS, the resident had a history of [REDACTED]. A review of R5's care plan revealed that the facility did update the care plan on 7/21/16, which stated that the resident had sustained a fall and that the new intervention was to encourage the resident to spend time in the common areas. There was no mention in the care plan that the resident would compulsively drink fluids, that the resident had a history of [REDACTED]. Cross refer to F323 The facility failed to implement the policies and procedures for fall prevention for R5. | 2019-08-01 |
| 4172 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2017-02-03 | 225 | D | 1 | 0 | KWE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of the facility's Abuse and Neglect Prohibition Policy and resident and staff interview, the facility failed to report to the State Survey Agency (SSA) an allegation of abuse for one resident (R#8) from a sample of (3) residents reviewed. The Census was 135 residents. Findings include: Review of the facility's Abuse and Neglect Prohibition Guidelines noted: Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation or resident property are at risk of occurring. The facility will conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin or misappropriation of resident property in accordance with state law. The facility will report such allegations to the state within 24 hours Review of the facility's Reporting and Response section of their Abuse and Neglect Prohibition Guidelines noted. The facility will report all investigation findings to the state within five (5) calendar days. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials within twenty-four (24) hours of identification. The facility will complete an incident/accident report in accordance with OP2 0401.02 incident/accident reporting for residents Review of the clinical record for R#8 revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 13 indicating she is cognitively intact. During interview with R#8 on 2/1/17 at 2:30 p.m., she was noted to speak slowly but clearly. R#8 indicated during interview that about a week prior to the interview, a nurse came into her room to give her medication about 9:30 p.m. or 10:00 p.m. R#8 further indicated that she told the nurse the potassium pill needed to be dissolved and the nurse got huffy, left the room and returned with a spoonful that contained the dissolved pill in applesauce. R#8 further indicated the nurse jammed and forced the spoon into R#8s mouth. R#8 revealed she was not physically injured but it caused her to be angry and upset. When asked if she had told anyone R#8 responded yes and indicated that on the following morning, she told the Activities person who comes by the room to check on each day and the Activities person put in a report about the incident. R#8 added, she only feels safe now when she knows the person taking care of her because she had never seen the accused nurse before that night. R#8 then indicated no one had talked to her about the incident since she reported it. R#8 further indicated she had not seen the accused nurse since the incident. During interview with the Activities Assistant AA on 2/1/17 at 3:02 p.m., revealed that she is the Ambassador to R#8 and stated She did tell me about the nurse jamming the spoon in her mouth. I went and told the Administrator and that the Administrator was going to go and talk to her. Activity Assistant AA further revealed she did not write a grievance regarding the incident involving the spoon and R#8 because she told the Administrator directly. Activity Assistant AA further indicated she did not know who the accused nurse is. When asked why she did not complete a written report of the abuse complaint, Activity Assistant AA revealed, I should have written it. During interview with the Administrator on 2/1/17 at 3:56 p.m., she denied knowing anything about the incident reported by R#8. The Administrator indicated the Ambassador is to go around to residents and find out what has happened. We discuss it in morning meeting and allegations are investigated beginning that day. The nurse would have been suspended pending the outcome of the investigation. When asked what her expectation is regarding staff reporting allegations of abuse, the Administrator indicated she expects abuse allegations to be written up and brought to her. During interview with the Activities Director (AD) on 2/2/17 at 10:15 a.m., he indicated that Activity Assistant AA did not report the incident with R#8 because she thought it was just an attitude issue. AD further indicated he would have told the Activity Assistant AA to follow-up to make sure the issue she reported was addressed. AD stated to me, the resident presented it as the resident was just saying the nurse was being a smart ass. AD further indicated, he did not consider the incident abuse so he would not have considered it an official grievance and it should not have been written up as one. AD went on the say For me, no matter what your perceptions are, even the smallest thing should be written down as a grievance. During an interview with the Interim Director of Nursing (DON) on 2/2/17 at 10:30 a.m. she revealed that she was not employed with the facility at the time of the incident and could not speak to the incident specifically. | 2020-02-01 |
| 3696 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2019-11-01 | 657 | G | 1 | 0 | T47P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of the facility's Falls Management policy, and staff interview, it was determined that the facility failed to evaluate the effectiveness of current interventions to prevent falls and failed to revise the FIP (Fall Intervention Plan) to include new interventions to prevent falls for one resident (R) (#1) of three residents reviewed for falls. This failure resulted in actual harm when R#1 sustained facial fractures after a fall on [DATE]. Findings include: Review of the undated facility policy titled Falls Management revealed that the goal of an intervention may not always be to prevent falls (but), to prevent injury .(Staff) should determine the cause of the fall and decide how a similar fall could be prevented for the resident (Staff) should update the FIP (Falls Intervention Plan) immediately and the date the intervention was put into place .At a minimum, the FIP will be reviewed with the MDS schedule and subsequent care plan review .A change in FIP should also trigger a note to explain reason for change (i.e , intervention no longer needed, intervention not working and why, etc.) .All falls should be reviewed daily by reviewing the medical chart to ensure that a new intervention was added to the FIP, evidence that an appropriate intervention was put into place to prevent further falls and the FIP updated. R#1 (a closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a medical decline and was admitted to Hospice Services on [DATE] for severe dementia. R#1 expired on [DATE]. Review of the Quarterly Minimum Data Set (MDS) for R#1 dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 3 indicating that he had severe cognitive impairment. R#1 had a care plan dated [DATE] for falls related to the use of [MEDICAL CONDITION] medication with the following interventions for nursing staff: Provide safe, clutter free environment; call light within reach with prompt response to all requests; ensure resident wears appropriate well-fitting foot wear to minimize the risk of slipping; safety training and education as needed; and prompt to ask for assistance. R#1 had a fall on [DATE] at 3:30 p.m. Staff encouraged R#1 to call for assistance and wait until he was assisted. The FIP revealed that staff initiated an intervention on [DATE] for staff to ensure that the resident's call light was in reach and consider his cognition. There was no evidence that staff evaluated the appropriateness of the intervention with respect to his impaired cognition. R#1 had a fall on [DATE] at 6:10 p.m. The Incident/Accident Report for this fall dated [DATE] revealed that licensed nursing staff documented that steps taken to prevent further occurrence of falls was to send the resident to the ER. There was no indication that staff evaluated the appropriateness of the intervention (send to the ER) or updated the resident's FIP with an appropriate new intervention to prevent further falls with injuries. R#1 had a fall on [DATE] at 4:00 p.m. The Nurses Notes for [DATE] revealed steps taken to prevent recurrence was to keep the resident's call light in reach and consider his cognition. Nursing staff updated the resident's FIP with an intervention dated [DATE] for staff to educate the resident on how to use the call light and to consider his cognition. There was no indication that nursing staff evaluated the appropriateness of the [DATE] intervention to prevent further falls based on the resident's impaired cognition. R#1 had a fall on [DATE] at 6:10 a.m. The Incident/Accident Report for the fall dated [DATE] revealed that there was no indication that nursing staff updated the FIP with appropriate interventions to prevent further falls with injuries. Review of the Significant Change MDS assessment dated [DATE] revealed that R#1 had a BIMS of 99, indicating severe cognitive impairment. Review of his care plan dated [DATE] and reviewed [DATE], [DATE] and [DATE] revealed the same interventions as his [DATE] care plan with the addition of an intervention for two staff to transfer the resident. R#1 had a fall on [DATE] at 5:50 p.m. The Incident/Accident Report for the fall dated [DATE] revealed that steps taken to prevent further recurrence were to monitor the resident frequently and encourage him to wait for assistance as needed. The FIP was updated on [DATE] with an intervention for staff to keep the call light in reach and consider the resident's cognition. There was no indication that nursing staff evaluated the appropriateness of the interventions or considered the resident's severe cognitive impairment. R#1 had a fall on [DATE] at 9:00 a.m. The Incident/Accident Report dated [DATE] revealed that steps taken to prevent recurrence was to recline the resident's Geri-chair. There was no indication that staff updated the resident's FIP to include the use of the Geri-chair or to keep it reclined. R#1 had a fall on [DATE] at 9:55 a.m. The physician ordered staff to place a tray on the resident's Geri-chair for safety. The FIP was updated to include the intervention of the tray but, there was no date documented as to its initiation. review of the resident's medical record revealed [REDACTED]. However, staff failed to update the FIP to indicate that the tray was discontinued. R#1 had a fall on [DATE] at 3:50 p.m. and sustained acute traumatic fractures of the left maxillary wall and left lateral orbital wall. The Incident/Accident Report for the fall dated [DATE] revealed that the steps taken to prevent recurrence was to monitor the resident closely. However, there was no indication as to the frequency of the monitoring (i.e., every 15 minutes, every 30 minutes, etc.). On [DATE], the physician ordered staff to place a floor mat next to the resident's bed. However, the FIP was not updated to include the fall mat. During an interview on [DATE] at 12:59 p.m., LPN AA stated that the nurse who completes the Incident/Accident Report is responsible for documenting a new intervention on the FIP. Further interview revealed that she notifies the on-coming nurse about the fall and the new intervention. Interview with the Director of Nursing (DON) on [DATE] at 3:46 p.m. revealed that the nurse was responsible for completing the Incident/Accident report after each fall and documenting an appropriate intervention to address the fall. Continued interview revealed that incidences that occurred the previous 24 hours including falls were discussed in the morning meeting. Staff determined the cause of a fall if possible and ensured that interventions were in place as care planned. The DON stated that she reviewed the Incident/Accident Report to ensure that any new interventions were appropriate. On [DATE] at 1:43 p.m., the DON reviewed the falls for R#1. She confirmed at that time that the intervention to keep the call light within reach and encourage the resident to use his call light and wait for staff to assist him was inappropriate based on his cognitive impairment for the falls on [DATE], [DATE] and [DATE]. Continued interview revealed that staff did not attempt to initiate a fall mat as an intervention on [DATE], [DATE] or [DATE] as a means to prevent injuries until after his [DATE] fall with major injury (facial fracture). Further interview revealed that the tray for the Geri-chair was discontinued on [DATE] and staff removed the tray without updating the care plan. Cross Refer to F689. | 2020-09-01 |
| 4952 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2016-03-21 | 514 | J | 1 | 0 | Z2SU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, Controlled Drug Record review, and Medication Administration Record (MAR) review, the facility failed to accurately document medications administered for two (2) residents (R#1 and R#3), from a sample of twenty-four (24) residents. 1. Specifically for Resident #1, who had [DIAGNOSES REDACTED]. to failure to document the 7:00 a.m. dose on the resident's MAR or Controlled Drug Record after administration. R#1 had been admitted with an order for [REDACTED]. The Physician was contacted two (2) times with the residents' complaints of ongoing pain and the facility received 2 additional physician orders [REDACTED]. The facility failed to record the subsequent physician orders [REDACTED]. 2. Additionally, Resident #3 received [MEDICATION NAME] Insulin seventy (70) units subcutaneously (sq) four (4) times, administration of [MEDICATION NAME] Diskus one (1) inhalation 1 time and Fluvall 0.5 ml intramuscular (IM) 1 time, during the month of October, without the accompanying documentation on the MAR. This resulted in a situation in which the facility' s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility' s Administrator, Director of Health Services (DHS), Corporate Clinical Consultant, and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on (MONTH) 25, (YEAR) at 5:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 14, (YEAR), the date another resident (#2) received two (2) antihypertensive medications with no order for these medications and was transferred emergently to the hospital, according to Nurses notes, fading in and out of consciousness with a blood pressure of 64/38. He was subsequently admitted to the ICU with a [DIAGNOSES REDACTED]. The Immediate Jeopardy continued through (MONTH) 20, (YEAR), the date Resident #1 received, due to an omission of documentation, two (2) doses of [MEDICATION NAME] 20 mg SL within 30 minutes, at 7:00 a.m. and 7:30 a.m. The night of 12/20/15 and the morning of 12/21/15, from 9:30 p.m. through 5:30 a.m. Resident #1 received [MEDICATION NAME] 20 mg SL every 2 hours without assessment of respiratory status, pain level and without regard to sedation level and education provided by a Nursing Supervisor advising the use of nursing judgement, the residents ability to use a pain scale to assess sedation, and the possibility of respiratory depression with the use of opioid medication. An interview with the Corporate Clinical Consultant on 2/18/16 at 5:00 p.m. revealed the investigation of these events had not resulted in identifying a problem with narcotic administration and monitoring or medication administration and documentation. The Immediate Jeopardy remained on going, pending the acceptance of a final Credible Allegation of Jeopardy Removal. Observations were made of medication administration to assess staff' s conformance with accurate documentation of medication administration. Record reviews were conducted to assess staffs conformance with correct scheduling of medications when transcribing orders to the Medication Administration Records. An allegation of jeopardy removal was recieved on (MONTH) 26, (YEAR). Based on corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on (MONTH) 1, (YEAR), and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staff's compliance with physician's orders [REDACTED]. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include 1. Record review for Resident #1 revealed an admission date of [DATE]. Physician orders [REDACTED]. Review of Physician orders [REDACTED]. This order did not specify the concentration or mg to be given. The next telephone order on the Physician order [REDACTED]. This order does not specify concentration of the liquid, route of administration or number of mg to be given. Review of the MAR for R#1 revealed the admission order for [MEDICATION NAME] had been transcribed with the concentration of 20 mg per ml, give 0.5 ml q 4 hours routinely. No time for the order appeared on the MAR and the times administered were recorded correctly. The next order transcribed to the MAR had no time when the order was received and was transcribed as [MEDICATION NAME] 1 ml q 3 hrs, with no concentration, mg, route or date. Two doses were signed as given on 12/19/15 at 8:00 a.m. and 11:00 a.m. The next order was written on the MAR as [MEDICATION NAME] 1 ml SL q 2 hours routine 12/19/15. No time of the order, concentration or mg was included. The order was initialed as given at 1:00 p.m. This order was marked as changed and rewritten with a concentration and no date or time and was initialed as given on 12/19/15 at 1:30 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., and 9:30 a.m. These doses were recorded as administered before the order existed. The next four doses on 12/19/15 at 11:30 a.m., 1:30 p.m., 3:30 p.m. and 5:30 p.m. were correctly recorded on the MAR then at 7:30 p.m. and 9:30 p.m. initials were crossed out. The 11:30 p.m. dose was initialed as given. Continued review of the MAR for 12/20/15 revealed [MEDICATION NAME] 20 mg/ml 1 ml was initialed as administered every 2 hours until the initials were circled at 3:30 p.m., 5:30 p.m., 7:30 p.m. and 9:30 p.m., indicating these doses were not administered. At 11:30 p.m. the [MEDICATION NAME] was initialed as administered. On 12/21/15 at 1:30 a.m., 3:30 a.m. and 5:30 a.m. the [MEDICATION NAME] was initialed as administered. Review of the Controlled Drug Record for R#1 revealed [MEDICATION NAME] was correctly signed as given on 12/19/16 at 2:00 a.m. and 6:00 a.m. Then a 0.5 ml/ 10 mg dose had been signed out without a time. The next dose on 12/19/15 at 8:00 a.m. is a 1 ml 20 mg dose in conformance with the order. According to review of the Controlled Drug Record the next doses of [MEDICATION NAME] were administered as ordered until a 20 mg [MEDICATION NAME] dose was given on 12/20/15 at 7:00 a.m. and another was administered at 7:30 a.m. Review of Corporate policy entitled Physician order [REDACTED]. Review of Corporate policy entitled Medication Administration: General Guidelines revealed if a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time the space provided on the front of the MAR is initialed and circled and an explanatory note is entered on the reverse side of the record. Continued review revealed after medication administration the MAR is initialed by the person administering the medication. Record review of Nurses Notes dated 12/20/15 at 1:30 a.m. by Licensed Practical Nurse (LPN) BB revealed no indication that medication was not given at the scheduled times. Review of the reverse side of the MAR revealed no note regarding a variation in the time [MEDICATION NAME] was administered. The following note written by the 7:00 a.m. to 7:00 p.m. LPN AA on 12/20/15 at 8:05 p.m. revealed that upon checking narcotic count at 7:00 p.m. a medication error was found. The 7:00 p.m. to 7:00 a.m. LPN BB had not signed out the doses of [MEDICATION NAME] administered at 4:30 a.m. or 7:00 a.m. and the day shift nurse AA had assumed the [MEDICATION NAME] had been administered at the correct time, which would have been 5:30 a.m. and administered a dose of 20 mg [MEDICATION NAME] thirty (30) minutes later at 7:30 a.m. AA documented notification of the physician and family, and an assessment of the residents respiratory status. LPN AA noted the physician had responded that since the two doses within 30 minutes had occurred twelve hours previously any adverse reaction would have already occurred. Interview on 2/18/16 at 5:15 p.m. with the Corporate Clinical Consultant revealed that this incident had been investigated and since there were no doses of [MEDICATION NAME] missing and it had measured out correctly this was not considered to be an error. The Corporate Clinical Consultant revealed that the policy for medication administration allows for a one hour variation before or after the medication is due, the administration of a dose of [MEDICATION NAME] due at 4:30 p.m. and given ninety (90) minutes later at 7:00 a.m., even though it was thirty (30) minutes past the allotted hour, was not considered an error. The Corporate Clinical Consultant acknowledged that the omission of documentation for the doses administered at 4:30 a.m. and 7:00 a.m. had resulted in 2 doses being administered within 30 minutes and the resident, already with a [DIAGNOSES REDACTED]. The Clinical Consultant indicated the unaccounted for dose of [MEDICATION NAME] recorded on the Controlled Drug Report on 12/19/15 without a time between 6:00 a.m. and 8:00 a.m. had been questioned with LPN AA and she had been unable to give an explanation of this entry, but this was also not considered an error. Review of Nurses Notes for R#1 dated 12/23/15 revealed an entry as follows: Investigation completed by Admin SR RN Consultant, DHS (DON). All meds, doses accounted for. No med error. This entry was signed by the Corporate Clinical Consultant. Interview on 2/19/16 at 10:35 a.m. with LPN AA revealed that when writing the orders for the increased doses of [MEDICATION NAME] she did not know she needed to include the concentration and milligrams. A indicated she also had not known the time of the order, concentration, and milligrams needed to be transcribed on the MAR, but she had received clarification of the last order on 12/19/15 at 3:30 p.m. by calling the physician and she rewrote the order with the concentration and mg at that time. LPN AA revealed that she had difficulty writing the scheduled times and this resulted in doses being initialed that were not given, before the order was written, and the MAR really could not be deciphered due to crossed out initials, circled doses, missing documentation on the back of the MAR, as well as doses initialed that were not actually given. LPN AA revealed that she had asked another nurse on duty on 12/19/15 how to correct the MAR and they did not have any suggestions. AA was asked about the extra dose signed on the Controlled Drug Report on 12/19/15 between 6:00 a.m. and 8:00 a.m. and she was unable to account for this. LPN AA revealed that when she arrived for work on 12/20/15 at 7:00 a.m. she discovered two doses of [MEDICATION NAME] for R#1, scheduled for 3:30 a.m. and 5:30 a.m. were not initialed as given on the MAR or signed on the Controlled Drug Report. She reported she assumed they had been administered as scheduled and the next dose due at 7:30 a.m. was administered as scheduled. LPN AA further revealed that she should have called LPN BB but did not. She acknowledged the narcotic count had been performed that morning before LPN BB left and it had looked correct but it was difficult to see the liquid because it was clear and it must not have been counted correctly. Continued interview revealed that she left 2 spaces on the Controlled Drug Report and asked LPN BB to fill in the spaces as well as the empty spaces on the MAR, when she returned on 12/20/15 at 7:00 p.m. When LPN BB filled in the time for her administration due at 5:30 a.m. as 7:00 a.m. AA reported to the physician, family and facility. LPN AA revealed that she should not have left empty spaces on the Controlled Drug Record. Interview with LPN BB on 2/19/16 at 11:55 a.m. revealed that she remembers not signing the MAR and Controlled Drug Record on 12/20/15 for the 3:30 a.m. and 5:30 a.m. doses she had administered late at 4:30 a.m. and 7:00 a.m. She was unable to remember why she had administered these doses late or why she had not reported this to LPN AA , or why she had not signed as having administered the [MEDICATION NAME]. She acknowledged leaving the spaces blank on the MAR and not documenting them on the Controlled Drug Report, and not reporting giving the last dose 90 minutes late to the oncoming Nurse had resulted in 2 doses of [MEDICATION NAME] being administered 30 minutes apart and this could have caused the resident to have a serious adverse reaction. LPN BB revealed there was no disciplinary action regarding the missing documentation, but someone had told her to be sure to document medication administration. 2. Record review for Resident #3 revealed a re-entry date of 6/29/15, with an admission [DIAGNOSES REDACTED]. Review of the (MONTH) Physician orders [REDACTED]. Review of the MAR for Resident #3 for the month of (MONTH) revealed [MEDICATION NAME] Insulin 70 units had not been initialed as given on 10/12/15 at 9:00 p.m., on 10/29/15 at 9:00 p.m., on 10/30/15 at 9:00 a.m. and 9:00 p.m. [MEDICATION NAME] Diskus 250/50 one puff q 12 hours had not been initialed on 10/13/15 at 9:00 p.m. and Fluvall 0.5 ml IM to left deltoid was to be administered on 10/25/15 and was not initialed. Continued review of the clinical record revealed Resident #3 had been in the facility on the dates the above medications were to be administered and there was no clinical indication not to administer the medications. The back of the MAR for the month of (MONTH) does not indicate the [MEDICATION NAME] Insulin, [MEDICATION NAME] Diskus and Fluvall were held for any reason. The Nurses Notes for the month of (MONTH) were reviewed and no indication of holding these medication on the above dates could be found. Interview with the Administrator on 2/19/16 at 2:30 p.m. revealed the documentation omissions for [MEDICATION NAME] Insulin 70 units sq a.m. and hs had been investigated by the facility as a follow up to a Quality Assurance Intervention that was considered resolved in August, (YEAR). The facility had determined the insulin had been administered and the nurses had received written disciplinary action for not documenting according to policy. The MAR' s are supposed to be checked by the unit manager at the end of each shift but there was no unit manager on the South Hall for the month of (MONTH) and the MAR' s did not get checked. The administration of Fluvall was documented in the Nurses' notes but never was documented on the MAR and the missing initials were not addressed and the administration of the [MEDICATION NAME] Diskus on 10/13/15 at 9:00 p.m. was never investigated. The Administrator confirmed that nurses are expected to initial the MAR according to policy, as soon as a medication has been administered. Interview on 2/25/16 at 1:35 p.m. with LPN LL revealed that she received counseling regarding missing documentation of [MEDICATION NAME] Insulin on 10/12/15 at 9:00 p.m. and 10/30/15 at 9:00 a.m. and remembered she had administered the insulin but had not documented. LL acknowledged also giving the [MEDICATION NAME] Discus 250/50 one puff q 12 hours on 10/13/15 at 9:00 p.m. but failed to document. LPN LL confirmed that she was aware that not documenting the administration of medications could lead to serious harm to the residents. Interview on 2/25/16 at 1:30 p.m. with LPN FF revealed that she had administered [MEDICATION NAME] Insulin 70 units to R#3 on 10/29/15 and 10/30/15 at 9:00 p.m. and had not initialed the MAR. She indicated she received counseling and was aware that missing documentation could have serious consequences for the resident. Based on the above findings omission of documentation on the MAR immediately following medication administration had a high likelihood of causing harm to two residents, Resident #3 with undocumented insulin administration, and Resident #1, with undocumented [MEDICATION NAME] administration resulting in 2 doses being administered in thirty minutes. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been only one (1) medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. Interview on 3/21/16 at 6:00 p.m. with the Director of Health Services (DHS) revealed all nurses are to monitor the MAR's for pictures and unsigned medications on the MAR's. The unit managers are also monitoring daily and the DHS monitors at least once weekly and checks the Controlled Drug Records against the MAR's, physician orders [REDACTED]. He further revealed he has not found any non-compliance. Medication pass is observed weekly for three (3) nurses, and the consultant pharmacist observes medpass monthly. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion. On 03/21/16 an extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. | 2019-03-01 |
| 4951 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2016-03-21 | 490 | J | 1 | 0 | Z2SU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, and review of established corporate policy and procedures, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently, to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure resident drug therapy was administered safely, accurately, and in accordance with physician's orders [REDACTED].#1 and #2) from a total survey sample of twenty-four (24) residents. Resident #1, with a physician order [REDACTED].(MONTH) 4, (YEAR), when he was transferred to an acute longterm care facility. Resident #2, who did not have an order for [REDACTED]. On (MONTH) 25, (YEAR), a determination was made that a situation in which the facility's non-compliance with one or more of the requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Health Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on (MONTH) 25, (YEAR) at 5:00 p.m. The Immediate Jeopardy was identified to have existed on (MONTH) 14, (YEAR), when the facility failed to ensure the accurate administration of medication to Resident #2. An allegation of jeopardy removal was received on (MONTH) 26, (YEAR). Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on (MONTH) 1, (YEAR), and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include: Review of the Corporate policy entitled Medication Discrepancies and Adverse Reactions revealed medication discrepancies and adverse reactions are to be reported to the patient/residents attending physician, the consultant and provider pharmacists, and the Pharmaceutical Services Subcommittee and/or the Quality Assurance Committee. Review of Procedure, Section 5 indicated a Medication Discrepancy/Adverse Drug Reaction Report is to be completed. Section 8 revealed the report is to be reviewed by the consultant pharmacist and on a quarterly basis by the Pharmaceutical Services Subcommittee and/or the Quality Assurance Committee and acted upon as appropriate. In addition to reporting discrepancies that result in the patient receiving an incorrect medication, medication discrepancies that have the potential for but do not actually result in the patient receiving an incorrect medication are documented and reported. Review of the Corporate Policy entitled Medication Administration; General Guidelines, Procedure #7 revealed patients/residents are identified before medication is administered. Procedure #9 indicated that in no case should the individual who administered the medications report off duty without first recording the administration of any medications. Procedure #10 revealed medications are to be administered within 60 minutes before or after scheduled time. Procedure #11 revealed after medication administration the patient/residents MAR indicated [REDACTED]. Review of Lippincott Procedures- Pain management, provided by the administrator when a pain management policy was requested, revealed under subheading of Giving medications: [REDACTED]. Reassess pain in a timely manner according to the onset of the prescribed medication. Reassessment should include not only pain relief but also adverse reactions or events produced by treatment. Cross refer to F329 regarding the facility's failure to administer [MEDICATION NAME] according to the Corporate Policy entitled Medication Administration: General Guidelines Cross refer to F333 regarding the facility's failure to administer medication correctly to Resident #1 and Resident #2, according to physicians orders, and according to the Corporate Policy entitled Medication Administration General Guidelines. Cross refer to F 520 regarding the failure of the Facility's Quality Assurance Committee to adequately monitor a plan of action to ensure an accurate and easily accessible method for staff unfamiliar with the resident's names to identify them for safe medication administration. In an interview conducted on 2/18/16 at 5:15 p.m. with the facility Corporate Clinical Nurse Consultant revealed she had investigated the administration of [MEDICATION NAME] 20 mg SL twice within thirty (30) minutes to Resident #1 on 12/20/15, but did not think this was an error because he did not receive an extra dose. The Corporate Clinical Nurse Consultant acknowledged the Medication Administration: General Guidelines policy indicates medications are to be given within one hour before or after the scheduled dose and this medication was administered ninety minutes late, but she did not think this was an error. The Consultant acknowledged BB LPN had not signed for 2 doses of [MEDICATION NAME] on the MAR indicated [REDACTED]. The Corporate Clinical Consultant confirmed [MEDICATION NAME] administration to a debilitated resident with a [DIAGNOSES REDACTED]. She acknowledged the [MEDICATION NAME] 20 mg SL had been administered every 2 hours on 12/20/15 beginning at 9:30 p.m. until the resident was discovered in respiratory distress with an oxygen saturation of 55%, and the only assessment for the 7:00 p.m. to 7:00 a.m. shift appeared on the reverse side of the MAR indicated [REDACTED]. Interview with the Clinical Competency Coordinator (CCC) on 2/23/16 at 9:45 a.m. revealed when LPN BB LPN and LPN AA were oriented in (MONTH) there was no CCC. The Minimum Data Set (MDS) Coordinator had to oversee staff education and orientation in addition to other assigned duties. She resigned in December, (YEAR). The CCC acknowledged the orientation of nurses has always consisted of a general orientation checklist, a skills checklist, computer learning modules, a medication test, and learning med pass with a preceptor. In an interview conducted on 2/24/16 at 3:00 p.m. with the Consultant Pharmacist, she revealed the Medication Discrepancy and Adverse Reaction reports were to review, track and trend medication errors and determine the need for interventions such as staff education. She acknowledged she had received a verbal report when Resident #2 received 2 antihypertensive medications and she had offered to observe a medication pass by LPN BB, but since BB was only in the building at night and on weekends she was not able to do this. The Consultant Pharmacist indicated she had also been made aware of Resident #1 receiving 2 doses of [MEDICATION NAME] within 30 minutes and his subsequent [MEDICAL CONDITION] the next morning and since he was admitted to the hospital she did not review any documentation for Resident #1. The Consultant Pharmacist acknowledged she had consulted for the facility since 2007 and had never received a completed Medication Discrepancy and Adverse Reaction Report. She confirmed these reports should be completed for any deviation from the Five Rights of Medication Administration, including right resident, right medication, right route, right time and right dose. Interview conducted on 2/25/16 at 3:30 p.m. with the Administrator revealed the administration of 2 antihypertensive medications ordered for Resident #4 and administered to Resident #2 on 10/14/15, was considered an error. The Medical Director had been notified and the error had been reported in the (MONTH) QA meeting. The intervention of assuring pictures of all the residents were on the MAR's had already been initiated and this was supposed to be monitored monthly by the unit managers. The Administrator acknowledged that on observations on 2/19/16 at 2:10 p.m. and on 2/25/16 at 10:40 a.m., of the one hundred eight (108) MAR's in the facility, there were six (6) missing pictures. The administrator indicated the unit managers must not be checking the MAR's for pictures. Continued interview revealed that Medication Discrepancy and Adverse Reaction forms were not completed for Resident #1 after receiving 2 doses of [MEDICATION NAME] within 30 minutes, or receiving scheduled doses of [MEDICATION NAME] every 2 hours without assessment of respiratory status or level of consciousness, or for Resident #2 who was administered his room mates medications. The Administrator revealed she had verbally informed the Consultant Pharmacist and the QA Committee of these situations, but there was no record of this. The facility had not completed these reports for any medication error for an unknown length of time. On 03/21/16 an extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been only one (1) medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion. | 2019-03-01 |
| 4693 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 323 | D | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility policy and procedure review, the facility failed to implement the policies and procedures for fall prevention for 1 resident (R5) out of 9 residents. Further, the facility failed to maintain a safe environment for the residents in one of four hallways ( D hallway cart) the medication cart drawer was broken and would not lock. Findings include: 1. R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, Section J, dated 4/28/16 identified that the resident was at high risk for falls. R5's care plan dated 4/29/16, identified the resident to be at risk for falls due to the use of cardiovascular and psychotropic medication use. One of the approaches identified was to .maintain a safe environment: clutter free, free of spills . The Nurse's Notes dated 7/21/16 documented that R5 sustained a fall, .Heard resident screaming in hallway. Observed resident sitting on the floor in a puddle of water in front of air conditioning unit outside of room . The resident did not sustain an injury per review of the Nurse's Notes. R5's care plan was updated on 7/21/16 and stated that the resident sustained [REDACTED].enfluence (sic) spending time in common area . A review was conducted of the facility's incident report and it documented that the resident was .ambulating in hallway, observed resident sitting on the floor in a puddle of water in front of air conditioner unit . There was no further investigation identified on this document that showed that the facility evaluated the fall or evaluated the potential for future falls by the resident. An interview was conducted with the Director of Health Services (DHS) on 8/19/16 at 11:40 a.m. along with the Corporate Nurse. When asked if there were any supportive investigative documents on the fall that R5 sustained on 7/21/16, the DHS stated that the resident was incontinent of bowel and bladder and that the resident had a history of [REDACTED]. Per the DHS, R5 poured water on the floor on 8/18/16. When DHS and the corporate nurse were asked again if there was any investigation on the resident's fall of 7/21/16, the DHS, said no. The facility's policy and procedure titled, Occurrences with a revised date of 5/4/2016 revealed, .Occurrence hazards are physical features in the healthcare center property which results in an injury or has the potential for injury .Any event, accident or incident, on or off healthcare center property which results in an injury or has the potential for injury .Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software .Occurrence investigation and follow-up is a joint responsibility within the healthcare center . 2. During the initial tour of the facility on 8/18/16 at 10:30 a.m. nurses were observed conducting medication administration pass on the D wing of the facility. Observation of the medication cart revealed the top drawer was broken and could not lock. Inside the drawer were the following medications: [REDACTED]. Colace 100 mg tablets 1 bottle. Residue of crushed medication in plastic packages, Sodium Bicarbonate 650 mg, Carvedilol 6.23 mg, Amlodipine 10 mg, and Namenda 10 mg. Five residents were observed seated in wheelchairs in close proximity to the broken medication cart. During an interview with the Director of Health Services (DHS) at 8/18/16 at 10:55 a.m. she reported she was not aware the medication cart drawer was broken and after speaking to her charge nurse she learned the medication cart has been broken for 2 days. | 2019-08-01 |
| 4066 | SEARS MANOR NURSING HOME | 115520 | 3311 LEE STREET | BRUNSWICK | GA | 31521 | 2017-04-25 | 329 | D | 1 | 0 | PUN411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of the facility's policy titled [MEDICAL CONDITION] Medication Monitoring, the facility failed to ensure behavioral monitoring was being completed for one resident (R), #1, who was receiving antipsychotic and antianxiety medications, [MEDICATION NAME] and [MEDICATION NAME] from a sample of three residents. Findings Include: The facility's policy [MEDICAL CONDITION] Medication Monitoring most recently dated (MONTH) (YEAR), revealed, 'Nurses will monitor behaviors and side effects and report to Medical Doctor (MD) as needed', and 'The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. Review of the medical record revealed that R#1 was admitted to the facility with diagnoses, per the Face Sheet including: [MEDICAL CONDITION] without behavioral disturbance, repeated falls, vitamin D deficiency, [MEDICAL CONDITIONS], essential hypertension, gastro-[MEDICAL CONDITION] reflux without esophagitis, [MEDICAL CONDITION] Stage 3 (moderate), and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] and the annual MDS assessment dated [DATE] indicated that R#1 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating the resident had severely impaired cognition. The resident was assessed as exhibiting no behaviors during the look back period. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no record in the MAR indicated [REDACTED]. Review of the Progress Notes for R#1 dated 12/2/16 through 4/23/17 revealed no evidence of any documentation of behaviors. Review of the Patient at Risk (PAR) notes revealed no behaviors had been documented. During an interview with the Director of Nursing (DON) on 4/25/17 at 11:00 a.m., she acknowledged that she was unable to find any documentation in the resident's clinical record to indicate the behaviors. Continued interview with the DON revealed she confirmed that monitoring for [MEDICAL CONDITION] medications was not on the resident's MAR. An interview with the MDS Coordinator QQ on 4/25/17 at 12:50 p.m. revealed that the resident had never been assessed with [REDACTED]. | 2020-08-01 |
| 4906 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2016-04-01 | 514 | D | 1 | 0 | 5HQU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and the facility records, the facility failed to ensure documentation of blood sugar results for one (1) resident ( L ) and failed to document why a medication was not administered for one (1) resident (#12). The sample was nineteen (19) residents. Findings included: 1. Interview on 04/01/16 at 12:35 pm with the Director of Nursing (DON) revealed that the nurse did not document the residents blood sugar on the 19th. She revealed that the nurse should have written the results of the 6:40 am blood sugar; but, she did not. Interview on 4/1/16 at 12:00 pm with the Staff Development Nurse GG revealed that the nurses are trained in orientation on documentation. She revealed that there are also computer classes that the staff are required to take on documentation. She revealed that the nurse should have documented the blood sugar results for the resident. She revealed that all staff has had inservices on documentation. Review of the policy titled Insulin Administration documented: Documentation includes: 1. The resident's blood glucose result, as ordered; 2. The dose and concentration of the insulin's injection; 3. Size and gauge of the needle used for injection; 4. Injection site (presence or absence of any bruising, pain, redness, swelling or unusual marks on or near the injection site); 5. How well the resident tolerated the procedure. Reporting : 1. Notify your supervisor if the resident refuses the insulin injection 2. Notify the physician if the resident has signs and symptoms of [DIAGNOSES REDACTED] that are not resolved by following the facility protocol for [DIAGNOSES REDACTED] management. 3. Report excessive bruising, swelling, pain, redness, or unusual marks on or around the injection site. Review of the Medication Administration Record (MAR) for Resident L indicated on 12/19/15 no data entry for 6:30 a.m. blood sugar report. Review of the Acknowledgement of Receipt Form dated 12/19/12 indicated Licensed Practical Nurse (LPN) PP had training on the facility's policies. Review of In-Service Attendance Record; Signature Sheet dated 2/9/16 indicated an in-service on documentation and that LPN PP was in attendace. 2. Review of the physician's orders [REDACTED]. Record review of the Medication Administration Record for Resident #12 for the month of (MONTH) revealed beside [MEDICATION NAME] 40 mg / 5 ml, give 2.5 ml PO QD, the initials of the medication nurse LL had been circled on 2/20/16, 2/21/16, another nurse whose initials were circled on 2/25/16, 2/27/16 and 2/28/16, and the space was blank under 2/26/16, all indicating the medication had not been administered on these dates. Review of the back of the MAR revealed no explanation was documented for Resident #12 for these six dates to not be administered [MEDICATION NAME]. Review of the Acknowledgement of Receipt Form dated 10/12/10 revealed LL LPN had received training on facility policy's policies Review of In-Service Attendance Record: Signature Sheet dated 2/19/16 Indicated LL LPN had attended an inservice on documentation. Review of facility policy entitled Documenting, page 27, #3. The MAR/ Treatment Administration Record (TAR) will then be reviewed daily by the DON/ Unit Manager (UM)/ designee to verify appropriate documentation is present. Interview on 3/31/16 at 12:10 p.m. with the Director of Nursing (DON) revealed the order to start [MEDICATION NAME] 40 mg /5 ml liquid give 2.5 ml's po qd had been transcribed to the (MONTH) MAR and the medication arrived from the pharmacy and was given as ordered on [DATE], 2/23/16, 2/24/16 and 2/29/16. The doses circled on 2/20/16, 2/21/16, 2/25/16 and 2/27/16 as well as the blank space on 2/26/16 should have had explanations on the back of the MAR and there are no recorded reasons why the liquid [MEDICATION NAME] was not administered as ordered. Interview 4/1/16 at 12:17 p.m. with the Staff Development Coordinator revealed that all nurses are expected to document on the back of the MAR an explanation of why any medication is not administered and have received this training, and LL LPN failed to document why [MEDICATION NAME] was not administered to Resident #12 two times in February. The Staff Developement Coordinator was not able to locate education records for the nurse who circled her initials on 2/25/16, 2/27/16 and 2/28/16, and said she was no longer with the facility. LL LPN was called but did not answer for an interview. | 2019-04-01 |
| 5076 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 282 | E | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, review of the Facility's Investigation Report and Facility staff Inservice Training Record review, the facility failed to ensure, for resident #30 was transferred with assistance of three staff assisting using the Mechanical Lift transfer as specified by the plan of care; for resident A, failed to obtain the Behavioral Health consult, failed to assess [MEDICAL TREATMENT] shunt site as specified by the plan of care, and: failed to notify the Physician of a cognitive change for one resident (#237), of the thirty-seven (37) sampled residents. Findings include: 1. For resident #30, the facility had identified a need for the resident to be transferred with the assistance of three (3) staff persons with a Mechanical Lift on the Transfer Assessment form which had initially been completed on 2/16/15. The assessment was based on the resident's physical condition, cognitive status and weight. The facility failed, however, to follow their plan of care, indicating the resident to be transferred with the assistance of three staff persons, to ensure the resident's safety during mechanical lift transfers. This failure resulted in a continued risk for subsequent falls during staff assisted transfers. Resident #30 had [DIAGNOSES REDACTED]. The resident had a plan of care of 1/29/15 for risk for falls/injury related to weakness, impaired mobility, cognitive loss, bilateral [MEDICAL CONDITION] since 2003, [MEDICAL CONDITION], balance deficit, incontinence, impaired vision and hearing, medication, and a history of falls. An intervention with the plan of care for this problem included to transfer the resident with appropriate devices, the use of the mechanical lift, and with three person assistance and to handle gently. An interview with certified nursing assistant (CNA) FF conducted on 1/7/16 at 4:30 p.m. revealed that she usually worked with this resident. CNA FF stated she worked with the resident on 12/22/15 at 6:00 a.m. CNA FF stated that she had just bathed the resident and called the charge nurse SS to help her to lift the resident from the bed to the wheelchair, using the mechanical lift. There was only CNA FF and Charge Nurse SS in the room to assist with the transfer. She further inaccurately stated that the resident required at least two staff person assistance with transfers for the mechanical lift and three staff assistance. The 1/7/16 written statement from CNA FF documented that while lowering the resident on to the reclining wheelchair, she discovered the resident was too far forward in the wheelchair, which began to tilt forward. Also, that she positioned herself behind the resident, with arms underneath the shoulders, while the Charge Nurse SS held the residents' legs and was unable to slide resident into proper position in wheelchair, the CNA FF and the Charge Nurse SS at that time slid the resident forward to the floor and slid the wheelchair out from underneath the resident. There was no injury to the resident. The facility failed to ensure that the plan of care for mechanical lift using three assistance was implemented on 12/22/15 when the resident was slid to the floor by CNA FF and charge nurse SS. Cross reference to F323. 2. Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Licensed nursing staff developed a plan of care on 9/16/15 that documented the resident was a new admission to the facility, had multiple medical problems, was alert and oriented and communicated without difficulty. A review of the clinical record revealed a 11/2/15 nurse's note entry that documented the resident complained of hearing and seeing things and of waking him/herself up at night by talking in his/her sleep. The plan of care was updated on 11/3/15 with a new intervention for a behavior consultation due to audio-visual hallucinations. After 11/3/15, although there was no evidence the resident continued to experience hallucinations, there was also no indication that licensed nursing staff had obtained the behavior consultation as care planned. During an interview on 1/8/16 at 12:25 p.m. the Assistant Director of Nursing (ADON) confirmed that the resident had not received the 11/3/15 behavior consultation to address hallucinations as care planned. Cross reference to F319. Licensed nursing staff developed a plan of care on 9/16/15 that documented that resident A was a [MEDICAL TREATMENT] patient and at risk for complications related to the shunt. The plan of care included interventions for licensed nursing staff to monitor the [MEDICAL TREATMENT] shunt every shift and following return from [MEDICAL TREATMENT] for bleeding and signs of infection; feel for thrill; auscultate bruit. Licensed nursing staff were to monitor the shunt dressing every shift to ensure the dressing was clean, dry and intact. However, a review of the clinical record revealed no evidence the [MEDICAL TREATMENT] shunt was being monitored as care planned. Licensed nurse PP stated on 1/7/16 at 1:35 p.m. that she worked with the resident infrequently but was aware the resident received [MEDICAL TREATMENT] and assessed the shunt site when returning from [MEDICAL TREATMENT]. Licensed nurse PP stated she had already checked the resident's shunt site on 1/7/16. Licensed nurse HH, who worked with the resident frequently, provided a statement on 1/8/16 at 9:54 a.m. documenting that she assessed the resident's [MEDICAL TREATMENT] shunt site after returning from [MEDICAL TREATMENT] treatments on Tuesdays, Thursdays and Saturdays. Resident A stated during an interview on 1/6/16 at 1:40 p.m. that the licensed nursing staff at the [MEDICAL TREATMENT] clinic assessed the shunt site on the days of [MEDICAL TREATMENT]. However, the resident stated licensed nursing staff at the facility did not assess the shunt site daily. However, there was no evidence in the medical record that the resident's [MEDICAL TREATMENT] shunt site was consistently monitored every shift, including on the days the resident did not receive [MEDICAL TREATMENT] as care planned. Cross reference to F309 3. Resident #237 had a 14 day MDS assessment with an Assessment Reference Date (ARD) of 9/27/15 completed by licensed nursing staff on 10/7/15. A quarterly MDS assessment with an ARD of 12/21/15 was completed on 12/23/15. A review of the MDS assessments revealed a decline in cognition from (MONTH) (YEAR) to (MONTH) (YEAR). The Brief Interview for Mental Status (BIMS) score declined from 12 to 5. Licensed nursing staff developed a plan of care, dated 9/30/15, that included the resident presented with memory recall deficit. The plan of care also included intervention to observe, document any changes in cognitive status, mood, behavior, sleep pattern, appetite, or infections and keep the Physician updated. However a review of the clinical record revealed no evidence that licensed nursing staff notified the Physician of the resident's decline in BIMS score from (MONTH) (YEAR) to (MONTH) (YEAR) as care planned. | 2019-01-01 |
| 3991 | ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY | 115727 | 113 SPRING VALLEY ROAD | JEFFERSONVILLE | GA | 31044 | 2017-08-10 | 309 | D | 1 | 0 | 5YLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed medical record review and staff interviews the facility failed to provide care and services in accordance with the admission assessment for 1 of 3 Residents (R#1) reviewed for care and services . The facilty failed to follow the physican's admission orders [REDACTED]. Finding include; Record review revealed R#1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Upon admission to the facility his [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Section I2900 revealed that R#1 was coded for diabetes mellitus. The facility failed to develop a care plan relative to managing diabeties. Review of the hospitial records prior to admission to the facility revealed orders dated 5/27/17 indicating that the resident was receiving insulin per sliding scale before meals and at bed time, in addition to insulin 10 units at bedtime. Upon admission to the facility a form titled, Physician's Interim/Telephone Orders dated 6/1/17 at 2:00 p.m., reflected an order to discontinue Basagllar Kwik Pen Insulin Glargihe Injections. During interview with R#1's physician on 8/10/17 at approximately 2:30 p.m., regarding the discontinued insulin order he stated, I do not remember all the details, but I believe there was no dosage for it, if I remember correctly. I held off on the insulin and did not start a sliding scale, because I was more concerned with the his behaviour since he was on multiple medications for his behavior. When asked about the blood glucose of 516 on 6/13/17, the physician said he would be more concerned with [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR), revealed orders to receive [MEDICATION NAME] 500 mg (milligrams) twice daily. It is documented on the MAR that R#1 refused [MEDICATION NAME] at least six times. The MAR reflects refusals of the [MEDICATION NAME] 500mg's at 9:00 a.m., on 6/3/17,6/14/17 and 6/15/17 and at 9:00 p.m., on 6/5/17, 6/1217, 6/13/17, 6/14/17 and 6/15/17. There was no documented evidence that the physician was notified of the medication refusals. During an interview with LPN AA on 8/10/17 at 1:00 p.m., regarding physican notification when resident's refuse medication revealed that, if they refuse three times I would call the physician. During a telephone interview with Licensed Practical Nurse LPN BB on 8/11/17 at 9:28 a.m., regarding the documention on a form titled, Skilled Daily Nurses Notes dated 6/13/17 at 3:30 p.m., revealed Labs including criticals are reported to the doctor. Review of laboratory results dated [DATE] on a form title, Clinical Laboratory Services, reflected a blood sugar of 518. During further interview with LPN BB he replied, when I saw the results on the desk I immediately called the Medical Doctor (MD) to report the BUN (Blood Urea and Nitrogen) and Blood Sugar, the MD said the resident was dehydrated and ordered an IV (Intervenous) fluid to hydrate the resident he was worried about the dehydration. LPN BB said, The MD (Medical Doctor) did not give any orders for ongoing assessment or vital signs and that the only intervention was IV fluids. I knew he had a change in condition when he was no longer fighting. Futher interview revealed that resident after resident started the IV fluids, that the vital signs are on the daily skilled note sheets, and we are only required to take them once on each 12-hour shift. The resident would have refused vital signs being taken and you don't have a right to do things as a nurse in Georgia without an order, I did it in Indiana but not in this state. LPN BB continued saying , I had thirty other residents to take care of and needed to pass medications, I can only do so much on a shift, you know if you don't have rights to do certain things you just can't do it, and I do the best I can from 7-7 when I get off. Upon futher record review of the Skilled Daily Nursing Notes, R#1's vital signs were documented on 6/13/17 D (Day) P ( Pulse) 102 R (Respirations) 16, B/P (Blood pressure) 120 /84, on the N (Night) P (Pulse) 105 , R (Respirations) 20 .B/P (Blood pressure) 136/93. There was no evidence found to indicate the staff assessed the resident for hypo or hyperglycemic symtoms. Recored review revealed on 6/15/17 a form titled Resident Transfer Form completed at 10:30 a.m., revealed the following documented BP (Blood Pressure) 144/92, HR (Heart Rate) 119 and RR (Respirations ) 18, FS glucose (Finger Stick Glucose) was left blank. and the reason for transfer noted , Lethergic, AMS (Altered Mental Status), not eating or drinking , chest congestion. Recod review revelaed that at 11:00 a.m., on 6/15/17 it was documented on a form titled, Physician's Interim/Telephone Orders, send to ER (emergency room ) Per Family Request, due to lethargy, not eating or drinking and chest congestion. There was no evidence that the residents blood glucose was monitored for the Glucose of 518 per the labortory results on 6/13/17. During a telephone interview with R#1's wife on 8/11/17 at 10:00 a.m., regarding his transfer to the hospital on [DATE], she stated his blood sugar was 700 when he got to the hospitial and he spent three days at the hospital in ICU (Intensive Care Unit) and then went to Hospice where he passed away. Wife stated she did not understand that he was in a diabetic coma that's what they told her at the Hospice center. | 2020-09-01 |
| 1954 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2018-07-26 | 842 | D | 1 | 1 | GMU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review and interview, the facility failed to provide a complete and accurate clinical record documenting the assessments, interventions and ongoing monitoring for one of 45 residents in the survey sample, Resident (R)#254 when her clinical condition rapidly declined on 4/10/18 requiring a transfer to the hospital. The findings include: Closed record review revealed R#254 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#254 was in the facility for less than 14 days and did not have a completed Minimum Data Set (MDS). The facility document Admission/Nursing Observation Form documented R#254 as being oriented times three (person, time and location), and requiring supervision with assistance with Activities of Daily Living (ADLs). A review of R#254's nursing notes revealed the following documentation for 4/10/18: 4/10/18 VS (vital signs) Temp (temperature) 37.6; P (pulse) 68; R (respirations) 40; B/P (blood pressure) 120/88. Skilled nursing provided. For nausea and vomiting receive [MEDICATION NAME] 4 mg (milligrams) at 1 p.m. PRN(as needed). Pt's L[NAME] (level of consciousness) decreased. MD (medical doctor) notified. Send to the (name of hospital) for further evaluation and treatments. See nurse's notes. No time stamp for this note. 4/10/18 2:30 p.m. Resident V/S's 129/6; 72 (pulse);18 (respirations) 98 (temp); 85% (O2 saturation) noted exhibiting episode of n/v (nausea/vomiting), attending nurse administered [MEDICATION NAME] x (times) 1 dose with effectiveness noted. Res (resident) position (sic) in bed. Skin color rosy and warm to touch, breathing pattern unlabored, HOB (head of bed) up for comfort. Attending nurse and staff monitoring. Signed by (name of former Unit Manager) 4/10/18 3:00 p.m. Resident continues worsening. Pt (patient) become clamy (sic). Slightly unresponsive. Pinpoint pupils observed. Vital signs taken: BP 84/60; P 63, O2 4/10/18 3:30 p.m. Condition worsen (sic). MD notified. Received order: NS (normal saline) 500 mg for 4 (four) hours. Condition worsened. Nursing call to send pt (patient) to the hospital. Transported to (name of hospital) for evaluation and treatment. Signed by RN DD. A review of the facility document titled SBAR (Situation, Background, Assessment, Recommendation) Communication Form completed for R#254 revealed the following documentation was not completed: Situation: The change in condition, symptoms, or signs observed and evaluated is/are: (incompleted). 40. Pulse Oximetry (O2 saturation) Resident Evaluation 2. Functional Status Evaluation: (not documented) 3. Behavioral Evaluation: (not documented) Abdominal/GI Evaluation: (not documented) 9. Pain Evaluation: (not documented). Recommendations of Primary Clinicians: (not documented). Nursing Notes: Transfer (name of hospital) for evaluation and treatment. On 7/25/18 at 2:15 p.m. an interview was conducted with Registered Nurse (RN) DD in the conference room. RN DD was asked what the process is for a change of condition. RN DD stated that she would call the doctor, obtain vital signs, document any objective changes, BP, temp, O2 sats and wait for response. She would wait on orders and follow the orders and document the information. RN DD was about the sequence of events regarding R#254's decline in condition on 4/10/18. RN DD stated Another nurse informed med the resident had declined and stated there was something wrong with her. I went in and did vital signs and they were not normal. When I was passing medications and the resident was fine when I gave her morning meds, perfectly fine. The Unit Manager had done 2:30 p.m. note and she is no longer at this facility. I gave her [MEDICATION NAME] (an anti- nausea medication) in the morning at 9 a.m. and it was effective. Sometime between 9:30 a.m. and 2:30 p.m. the resident had therapy. The Unit Manager was checking on the resident at 2:30 p.m. and came to find me and tell me something was wrong. I went to check on resident and checked the vital signs she was unresponsive with pinpoint pupils and abnormal vital signs with respirations of 40 breaths per minute. I called the doctor. When asked about the time between 3 p.m. and 5 p.m. when the EMS (Emergency Medical Services) dispatch went out, RN DD stated that she called the doctor and the nursing manager. RN DD stated that she thought her recorded time was incorrect as she was passing medications for the afternoon and she started that around 4 p.m. And it was during that medication pass the Unit Manager alerted her that R#254 wasn't doing well. An order was received from the MD at 4 p.m. and EMS was called at 5 p.m. RN DD was unable to identify the other nurses working her during while the resident was assessed. When the EMS arrived RN DD stated that she gave report and was able to answer all the questions. RN DD stated that she did give the EMS staff written documentation. RN DD added, I gave them the SBAR information and transportation sheet. RN DD reviewed her documentation and was asked if she had included her assessments, interventions and monitoring in her documentation. RN DD stated that she had not completed the documentation. RN DD further stated that she knew that she had applied oxygen, monitored the vital signs during the event and that a nurse did come into the room and insert an IV. When asked why all those things were not documented, RN DD stated that it was so busy that she did not document any of what happened. On 7/25/18 at 3:15 p.m. an interview was conducted with the Staff Development Nurse (SDN) in the conference room. When asked if she remembered the situation with R#254 the SDN stated I don't but sometimes I run out and help when a resident is not doing well. I think I was asked to start an IV, and I am sure that we put a monitor on her arm and kept getting frequent vital signs. The SDN also stated that she did not remember any details regarding the situation and did not document anything. On 7/25/18 at 3:17 p.m. an interview was conducted with the Director of Nursing (DON) in the presence of the Administrator in the Administrator's office. The DON and Administrator were provided the details of the concern. The DON was asked during a critical situation with a resident what should the nursing staff do. The DON stated that the staff should be monitoring the vital signs and documenting their findings. The DON further stated that normally a nurse is doing the assessments and another staff member is writing the results. The DON was shown the documentation provided for R#254 on 4/10/18 when her medical condition declined. The DON stated that the staff should have documented all the vital signs obtained, the IV insertion, and that the resident was provided fluids per the physician's orders [REDACTED]. The documentation did not provide a complete and accurate picture of what occurred with R#254. The facility was unable to provide policies and procedures giving the staff on directions for evaluating and assessing residents experiencing change in condition and providing a complete report to the emergency medical staff. The Administrator confirmed the facility did not have policies for the above situation, however, the Administrator provided a print out from Lippincott Procedures printed from the following website http://procedures.lww.com for Documentation, Long-Term Care. The following documentation was included: Documentation is the process of preparing a complete record of a resident's care and is a vital tool for communication among health care team members. Accurate, detailed documentation shows the extent and quality of the care that nurses provide, the outcomes of that care, and the treatment and education that the resident still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors and promotes continuity of care. Document information as soon as possible to ensure the accuracy of the information and to reflect ongoing care. Delayed documentation increases the potential for omissions, error and inaccuracy due to memory lapse. Document the resident's vital signs, your assessment findings, the resident's care plan, your interventions, teaching provided to the resident and family and their understanding of that teaching, and the resident's response to your interventions. | 2020-09-01 |
| 2934 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2017-10-26 | 315 | D | 1 | 1 | 9WJL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, interview, and review of facility policy, it was determined the facility failed to ensure two Residents (R)#26 and (R)#129 from a sampled 34 residents with a catheter received the appropriate care and services to prevent infection and trauma. The findings include: 1. Review of a facility document titled Suprapubic Catheter revised 5/23/17 documents the purpose is to provide proper care of the catheter site to reduce skin irritation and and/or infection. The document indicates the care procedure and documentation of care in the treatment record. Closed record review revealed R#26 was admitted to the facility 4/10/17 with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. The resident was coded as requiring total assistance with bed mobility, transfer, and activities of daily living; continent of bowel and using a suprapubic catheter; and fall history. Review of the resident's catheter care plan with a revision date of 6/4/17 indicates the resident was at risk for UTIs related to the suprapubic catheter. Interventions include observe for pain/discomfort due to catheter; encourage fluids by mouth; change suprapubic catheter monthly; position catheter drainage bag and tubing below the level of the bladder; check tubing for kinks during rounds and as necessary; suprapubic catheter care as ordered; treatment to catheter are ordered; and leg strap on catheter tubing to promote proper drainage. Review of physician orders dated 4/23/17 revealed the following; - monitor suprapubic catheter site every shift for signs of infection - position drainage bag and tubing below the level of the resident's bladder - catheter care every shift with warm water and soap - encourage extra fluids every shift to prevent risk of infection - leg strap on always to promote drainage - change suprapubic catheter monthly and as needed. Review of physician orders dated 5/9/17 revealed the resident was to receive Xeroform dry dressing every day to the suprapubic catheter site. A review of the treatment administration records (TAR) for the month of (MONTH) (YEAR) revealed the staff failed to document 13 days that the resident received the Xeroform gauze dressing to the suprapubic catheter site. Also, the staff failed to document nine days that the resident received catheter site care. The (MONTH) (YEAR) TAR sheets show the facility failed to document the resident receiving catheter care, the presence of the catheter strap and the position of the draining bag on 22 shifts. The (MONTH) (YEAR) TAR sheets show the facility staff failed to document the resident receiving catheter care, the presence of the catheter strap and the position of the draining bag on 28 shifts. A review of the nurses' notes dated 8/4/17 revealed the resident was started on Keflex 250 milligrams for UTI. An additional review nurses note dated 8/8/17 documents the resident had redness with no drainage around the suprapubic site. Continued review of nurses' notes dated 10/8/17 documents the resident continues antibiotic therapy for an infected suprapubic catheter; site is slightly red no drainage swelling or odor noted. Interview on 10/23/17 at 7:30 p.m. with R#26's family member revealed the family had concerns about the resident's care especially the resident's suprapubic catheter. The family stated resident had developed a urinary tract infection due to the staff's failure to care for the catheter properly. The family member stated there were times when visiting the resident suprapubic catheter site did not have a dressing covering it. An interview with the Director of Nursing (DON) on 10/25/17 at 3:30 p.m. on the West Hall revealed the facility utilized agency nurses during this period time and it was identified there was problem with the staff documenting treatments appropriately. An interview with Licensed Practical Nurse (LPN) OO on 10/26/17 at 1:30 p.m. on the West Hall nurses station revealed she had provided care to R#26 on 10/21 and 10/22; however, she did not perform the catheter site care becThe facility failed to ensure R#26 received the appropriate treatment for [REDACTED]. ause the resident had just returned from the hospital on [DATE] and the treatment was not re-ordered. The LPN further stated that she did not contact the MD about re-ordering the suprapubic catheter treatments. 2. Review of the facility policy titled Indwelling Catheter Care (SHCRC .06) revised 5/23/17 noted the following: Procedure: 12. Provide enough slack before securing catheter to prevent tension on tubing. Use Velcro strap to secure tubing to the thigh. Resident # 129 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#129 had a Brief Interview for Mental Status (BIMs) score of 14, indicating the resident was cognitively intact. R#129 required extensive assistance with bed mobility, transfer, locomotion on and off the unit, dressing, toileting, and personal hygiene. The resident had no impairment to the upper extremities but had impairment bilaterally to the lower extremities. The resident had an indwelling catheter for bladder function and was always incontinent of bowel. Review of R#129's care plan revised on 3/14/17 revealed the resident was At risk for recurrent urinary tract Infections (UTIs) related to use of Foley catheter and history of urosepsis prior to admission. Diagnosis: [REDACTED]. The goal revised on 10/25/17 noted the resident will be free from catheter related trauma through the review date. Interventions included Secure Foley catheter with strap to leg.: An interview conducted on 10/25/17 with Certified Nursing Assistant (CNA) EE revealed that she gives R#129 a bed bath and provides catheter care. She revealed that the resident gets out of bed with a Hoyer lift and the assistance of two staff members. During an observation of wound care on 10/25/17 at 4:03 p.m. R#129's Foley catheter was noted to be unsecured. There was no leg strap present and the tubing was not fastened to the sheets in a manner to prevent tension on the resident's catheter. During the observation, an interview was conducted with Registered Nurse (RN) A[NAME] AA, confirmed the Foley catheter should have been secured with a leg strap. An observation conducted on 10/26/17 at 9:46 a.m. revealed R#129's Foley catheter remained unsecured with a leg strap or other device. An interview conducted at 9:50 a.m. with certified nursing assistant (CNA) GG revealed that she did not know if R#129 should have a leg strap for his catheter. GG stated that most of the residents' catheters were secured by a leg strap. | 2020-09-01 |
| 1951 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2018-07-26 | 692 | D | 1 | 1 | GMU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, interview, and review of facility policy, the facility failed to ensure one of four residents (R) (R#152) reviewed for nutrition was screened and assessed by the Dietary Manager and Dietitian in accordance with facility policy and served the correct diet. These failures placed the resident at risk for choking, aspiration (inhalation of food, stomach acid, or saliva into the lungs), weight loss and exacerbation of other nutritional problems. Findings include: Closed record review revealed R#152 was admitted to the facility on [DATE] following hospitalization ; the resident was discharged home on[DATE]. R#152 was not in the facility during the survey. Review of a document titled Notification of Admission Form dated 7/3/18 revealed the resident had been living with her son prior to admission with plans to return home after rehabilitation. [DIAGNOSES REDACTED]. The reason for the resident's hospitalization was abdominal pain for one to two weeks with nausea and vomiting. The resident was also newly diagnosed with [REDACTED]. The resident was documented as being on a mechanical soft diet. Review of the resident's Baseline Care Plan dated 7/3/18 indicated the resident's goal was to increase strength so she could go home. The resident was documented as having experienced an activity of daily living (ADL) decline related to a stroke. The goal was for the resident to improve ADL function to maintain independence through the next 30 days. The care plan identified a problem of diabetes and risk for hyper or [DIAGNOSES REDACTED]. The goal was for the resident's blood sugar to be maintained to the next 30 days. The nutrition section of the care plan was blank, it had not been filled out. The Admission/Nursing Observation Form dated 7/3/18, under the section titled Eating revealed the resident was on a mechanical soft diet and she had a poor appetite. Review of a document titled Hospital Patient Visit Report dated 7/3/18, under Instructions documented the resident's diet was resume previous diet. Review of the initial physician's orders [REDACTED]. Review of the facility form titled Dietary Communication Form dated 7/3/18 at 3:30 p.m. indicated the resident was on a regular consistency diet. Review of a physician's telephone order dated 7/4/18 revealed orders for speech therapy evaluation and treatment as indicated. The resident was to be treated for [REDACTED]. Review of facility document titled SAFE Swallowing Ability and Function Evaluation form dated 7/4/18 indicated the resident had moderate deficits in oral and pharyngeal phase with mastication bolus and decreased swallowing and was at increased risk for aspiration. The document indicated the resident's diet was changed from regular consistency to mechanical soft. The Dietary Communication Form dated 7/4/18 at 2:30 p.m. indicated the resident was be served a mechanical soft diet with chopped meats. The next dietary communication form (undated), undated documented the resident was to receive a soft mechanical diet. On 7/6/18 the Speech Therapist recommended a diet change to mechanical soft with pureed meats; a telephone order was written for the texture change. The Yearly Weight Record Form indicated the resident was weighed once on 7/7/18. On this date the resident's weight was 125.8 pounds. The resident was 5'3 tall. Review of the Skilled Daily Notes documented by nursing staff revealed there were no notes related to the resident's diet, not receiving the right foods, or any other nutritional/dietary concerns being raised by the resident or her family. The entire closed record for R#152 was reviewed. There was no documentation of a nutrition screening or assessment in the record. The only documentation from dietary consisted of a food preference form completed on 7/6/18. The resident was at risk for adverse nutritional outcomes related to [DIAGNOSES REDACTED]. The family of R#152 was interviewed on 7/25/18 at 11:30 a.m. over the phone. The Family of R#152 stated the resident was served a hamburger the first meal after she was admitted to the facility. He stated another family member was with the resident and stopped the resident from eating it. The Family of R#152 also stated the resident had received mechanically altered foods in the hospital and she was unable to eat regular food. The Family of R#152 further stated the family made the staff (speech therapist and nursing) aware of the situation so the diet could be corrected. The Family of R #152 added the resident received a second serving of regular meat the next meal after the diet order problem had been brought to the attention of staff on 7/3/18. Family of R#152 stated the resident had a stroke and it was unsafe for her to eat regular food. The Family of R#152 also stated a nurse was notified of the wrong diet following the second meal. He stated the diet texture was corrected after the second meal when the resident was served regular meat. The following staff interviews verified the resident was not screened or assessed for nutritional status and was served the wrong diet texture initially: -Licensed Practical Nurse (LPN) GG was interviewed on 7/25/18 at 2:45 p.m. in the Family Dining Room. LPN GG stated one of R#152's family members was with the resident most of the time during days and evenings over the course of her stay. LPN GG stated there had been several issues raised about the resident's diet. LPN GG stated, It seemed like a miscommunication with family. At first, they wanted pureed, then mechanical soft, and then pureed foods. LPN GG stated the hospital orders called for a mechanical soft diet to be served when she was admitted on [DATE]. -Certified Nurse Assistant (CNA) HH was interviewed on 7/25/18 at 3:40 p.m. in the Family Dining Room. She stated she remembered the resident and family, stating she did not remember any concerns regarding the resident's diet. CNA HH stated she remembered the family bringing the resident food to eat during her stay. -The Registered Dietitian (RD) was interviewed on 7/25/18 at 3:55 p.m. in a conference room. The RD explained how the nutrition screening and assessment process worked. She stated a nutrition screening/assessment was completed by the Dietary Manager and herself. She stated the Dietary Manager completed the first page of the document (nutrition screening) as well as a food preference form within five days of admission and she completed the second page (nutrition assessment) later. The RD stated she completes the assessment for high risk residents (those with wounds, on tube feedings, and on [MEDICAL TREATMENT]) within seven days of admission. And she completes the nutrition assessments for all other residents in the order they were admitted . The RD added there was no deadline for completing nutritional assessment for newly admitted residents. She reviewed the resident's closed record and verified there was no nutrition screening or nutrition assessment in the record. The RD stated, I do not remember assessing her. I probably would not have seen her if she was not at high risk. The RD stated there were a lot of residents admitted for rehabilitation with short stays. The RD indicated she was not in the facility the first week in (MONTH) (YEAR); however, was in the facility on 7/12/18 or 7/13/18. The RD verified she had not assessed the resident and did not have any direct contact with, or firsthand information about the resident. The RD confirmed according to the facility's nutritional assessment policy this resident's nutritional assessment should have been completed within 14 days of admission Continued interview with the RD revealed she reviewed the resident's closed record and stated the Admission/Nursing Observation Form dated 7/3/18, indicated the resident was prescribed a mechanical soft diet in the hospital and that was her diet order when she was admitted . The RD reviewed the handwritten physician's orders [REDACTED]. She stated, I don't know where that (regular diet order) came from. -The Director of Nursing (DON) was interviewed on 7/25/18 at 4:15 p.m. in a conference room across from the Family Dining Room. The DON indicated she had been in her position as DON for about a week and prior to that, she was the Unit 1 Manager (the unit where R#152 had resided during her stay). The DON verified the Admission/Nursing Observation Form dated 7/3/18, indicated the resident's diet order was mechanical soft. The DON reviewed the handwritten physician's orders [REDACTED]. The DON stated she was aware the resident was served a regular diet which included a hamburger on 7/3/18 and verified the resident's family had spoken with her about it. The DON also stated the resident was served regular fish (not mechanical soft or pureed) and the resident's family was also upset about that, saying it was not soft enough. The DON further stated the resident's diet order was changed several times during her stay, to pureed, mechanical soft, and then to mechanical soft with pureed meats. -Licensed Practical Nurse (LPN) II was interviewed on 7/25/18 at 5:04 p.m. in the conference room across from the Family Dining Room and verified she was the nurse who documented a regular diet on the initial physician's orders [REDACTED]. LPN II retrieved a document titled Patient Visit Report, dated 7/3/18 and it read under diet: Resume Previous Diet. The diet order was not clear; the resident was on a mechanical soft diet while in the hospital and prior to her stroke and hospitalization , had eaten regular foods. LPN II stated she did not know what the texture was supposed to be, so she documented regular texture on the orders and told the admitting nurse on the 100 Unit, the texture needed to be clarified. LPN II stated she was helping on the 100 Unit and she was not the admitting nurse for the resident. She stated her position was Unit Manager of the 200 Unit. The facility was unable to provide documentation of the need to clarify the diet order or evidence that this was communicated. -The Speech Therapist (ST) was interviewed on 7/26/18 at 9:43 a.m. in his office. He stated he was not the ST who worked with the resident; this staff member was not working. However, the ST was able to access the ST records and opened the initial ST evaluation completed on 7/4/18. He stated R#152 was prescribed a mechanical soft diet with chopped meat on 7/4/18, the day after admission. The ST stated the evaluation indicated the resident experienced frequent coughing and throat clearing during the ST evaluation. He further stated the resident experienced moderate oral retention or residue after she swallowed. When asked about the diet order that read Resume Previous Diet he stated the diet should have been clarified by the nurse. ST stated the consistency of the diet order should have been documented under the hospital discharge orders. The ST stated, She would be at risk eating regular hamburger with the issues documented in the assessment. The ST stated the resident's meat needed to be chopped into bite sized pieces. -The Dietary Manager was interviewed on 7/26/18 at 11:11 a.m. in the dining room and verified she did not have a copy of the nutrition screening form and did not know if she had completed it. The Dietary Manager also stated she usually completed the food preference form and nutrition screening at the same time. Review of the facility document titled Nutritional Screening and Assessment - Food Preferences Policy revised on 11/21/16 indicated it was the policy for residents to receive an initial nutritional screening and comprehensive nutritional assessment upon admission. Under procedure, the dietary manager was directed to review the nursing admission assessment form and complete the initial screening portion of nutrition screening and assessment form within five days of admission for all residents. The Registered Dietitian was to complete the nutritional assessment within 14 days of admission if the facility was a joint commission facility. The resident resided in the facility 17 days and was not screened by the Dietary Manager or assessed by the Dietitian. | 2020-09-01 |
| 4141 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2017-03-24 | 241 | D | 1 | 0 | BIP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on complainant and staff interviews, and the Grievance Log, the facility failed to ensure the promoting of self esteem and self-worth of one (1) resident (R#4) from a sample of twelve (12) residents. Findings include: Interview on 3/20/17 at 12:30 p.m. with the Complainant revealed that the (R#4) no longer wants to be in the facility. She revealed that the staff would not always answer the call light. She revealed that on the day that R#4 was sent out to the emergency room (ER), (MONTH) 2, (YEAR), the Certified Nurse Assistant (CNA) did not provide care for her. She revealed that R#4 was wet from head to toe on the day after admission and that the staff did not change the resident when she first came in and that she had brown rings in the bed. The complainant revealed that she had shown this to the nurse and the certified nursing assistant. Record review reveals the resident was discharged on [DATE], to the hospital, and was admitted to another facility upon discharge from the hospital. Interview on 3/21/17 at 7:00 p.m. with the Administrator revealed that she had no conversations with the Complainant concerning any allegations. Interview on 3/22/17 at 11:50 a.m. with Certified Nurse Assistant (CNA) BB revealed that the pads under the resident was brown because the resident did not have on a brief. She revealed that the R#4 was wet. Interview on 3/22/17 at 1:08 p.m. with Licensed Practical Nurse (LPN) DD revealed that R#4 talked about she was worried that there was not enough staff to to assist with her care. She revealed that R#4 also revealed that she felt like the Certified Nurse Assistants (CNA's) were not paying her any attention because of her size. She revealed that the R#4 reported that she felt uncomfortable. LPN DD revealed that she went to the the room of R#4 when the family member came and got her. She revealed that the resident was wet and that the sheets had small brown rings. Interview on 3/26/17 at 1:00 p.m. with the Complainant revealed that she had made several phone calls to the Administrator with no response to her concerns. Review of the Grievance Log dated 8/31/16 indicated a grievance filed concerning (R#4) was wet from urine from shoulders to feet. Further review of Grievance log dated on 12/13/16 indicted (R#4) left wet from 0600 until 1600. | 2020-03-01 |
| 4790 | PRUITTHEALTH - FAIRBURN | 115506 | 7560 BUTNER ROAD | FAIRBURN | GA | 30213 | 2016-06-09 | 333 | D | 1 | 0 | WGW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on complainant interview, staff interviews and the Medication Administration Record [REDACTED]. Findings include: Resident E was admitted to the facility on [DATE] with multiple diagnosis, including: Weakness, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), high Cholesterol, [MEDICAL CONDITIONS], Dementia, Hypertension, Decreased appetite, [MEDICAL CONDITION] Ulcer, Chronic [MEDICAL CONDITION], Depression, Vascular Neurocognitive Disorder with Behavioral problems. The resident had a physician's orders [REDACTED]. Apply patch to skin every day. Remove old patch. Rotate site and do not repeat the site for fourteen (14) days. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on 5/18/16 at 10:30 a.m. with the Complaint D revealed that he had concerns about all of the patches being left on resident E and not being changed. He revealed that the staff could not have been assessing the resident and leaving all the medicine patches on her. Interview on 5/18/16 at 2:32 p.m. with Licensed Practical Nurse (LPN) AA revealed that there were inservices every so often on patches. She revealed that on the 3-11 shift, the nurse is to check and make sure that the medication patch is on and in place. She revealed that the resident is physically checked. She revealed that if the patches are not in place, she would notify the supervisor and called the resident's physician. Interview on 5/18/16 at 2:35 p.m. with LPN BB of the 300 Hall revealed that she worked with resident E on (MONTH) 3rd, (YEAR). She revealed that she took off the old patch and put on a new one. She revealed that the old medication patch would have had a date of 4/2/16 written on it. She revealed that she had inservices on how to administer medication patches. Interview on 5/18/16 at 3:00 p.m. with LPN HH on the 200 Hall revealed that she has had inservices on how to administer medication patches. Interview on 5/19/16 at 9:15 a.m. with the Interim Administrator ZZ revealed that an investigation was completed on why the resident E had on extra patches and as a result, inservices for all nurses were done on 4/12/16. Interview on 5/19/16 at 9:30 a.m. with LPN JJ by telephone revealed that she put the (MONTH) 6, (YEAR) patch on. She revealed that she removed a patch before she put the new one on. She revealed that she did not check the resident's whole body for any patches. She revealed that she had never put any patches any other place other than the resident's back and arm. She revealed that she attended an in-service on [MEDICATION NAME]es. Interview on 5/19/16 at 9:43 a.m. with LPN KK by telephone revealed that she worked the 11-7 shift. She revealed that she put on one (1) patch and remove the other patch. She revealed that the patch was scheduled for 6 a.m. in the morning; but, it was usually given at 9 a.m. She revealed that at that time was scheduled at 6 a.m. She revealed that she has had an in-service on the [MEDICATION NAME] Patch. She revealed that her main responsibility for residents with patches, is to look at the whole body. Interview on 5/19/16 at 10:00 a.m. with LPN LL by telephone revealed that she looked for another patch on resident E. She revealed that she took off one (1) patch and put on a new patch on. She revealed that she assumed that the patch should not be put on the upper back. She revealed that she has had an inservice on the patch. Interview on 5/19/16 at 11:00 a.m. with the Nurse Practitioner (NP) revealed that the some side of effects [MEDICATION NAME] are gastro-intestinal disturbances, nausea, and vomiting, can cause fatigue. She revealed that the patches should have been removed; and that the resident should never have on more than one. She revealed that the resident has a history of being lethargic; and, that she has been sent out to the hospital before being lethargic. Review on the Medication Administration Record [REDACTED]. Apply one (1) patch to skin every day. Remove old patch (rotate site & do not repeat site for 14 days). (For [MEDICATION NAME]). If further indicated that patch was applied to resident E on (MONTH) 1,2,3,4,5, and 6 , (YEAR). Review of the United Pharmacy Services [MEDICATION NAME] Patch Site Rotation Schedule indicated all [MEDICATION NAME] Patches need to be removed after 24 hours and replaced by a new patch. It further indicated that it is important for healthcare professionals to instruct patients and caregivers on the proper use of the [MEDICATION NAME] and particularly that: only one (1) [MEDICATION NAME] should be applied per day to healthy skin on only one of the recommended locations: the upper or lower back, or upper arm or chest; the patch should be replaced by a new one after 24 hours/ and the previous day's patch must be removed before applying a new patch to a different skin location.; to help minimize skin irritation, application to the same skin location within 14 days should be avoided. It further indicated that the site for all [MEDICATION NAME] Patches needs to be recorded daily on the MAR. Review of the Medication Administration: [MEDICATION NAME] Drug Delivery System (PATCH) Policy: When administering medication via [MEDICATION NAME], nurses will follow current standards of practice to facilitate continuous medication absorption of the medication through the patient/resident's skin while the patch is in place. Nurses will provide proper care to the application site and application sites will be rotated per manufacturer's recommendations. Procedure and Key Points: #7. Observe site of previous patch application, gently remove old patch and dispose of according to health care center policy. #8. Select an appropriate site for application of new patch. Rotate site of application. Date and initial new patch before application. An telephone interview with the resident's family on 6/3/16 at 1:20 p.m. revealed the resident was admitted to the hospital on [DATE] after the family insisted due to change, over the last twenty four (24) hours, in the resident's cognitive condition and somnolence. The family member stated that upon arrival in the hospital emergency room (ER) it was discovered that the resident had three different [MEDICATION NAME] Patches on her back. The family member took photographs of the patches which were supplied with the complaint. The family member brought this to the attention of the ER physician who contacted Georgia Poison Control Center regarding if the patches could be causing the symptoms. The family member also contacted the facility regarding these findings. A telephone interview on 6/8/16 at 6/8/16 with the Director of Nursing (DON) requesting an interview with the Consultant Pharmacist. The DON revealed, at this time, that using the pharmacy [MEDICATION NAME] Patch Rotation Sheet was a recommendation but not a requirement. She states the nurses should check the resident's skin before applying a new patch. She revealed that the rotation of the patches is noted on the resident's MAR using the corresponding number of 1-31 to identify where the patch was placed. The patch is to be dated and initialed by the nurse. A telephone interview on 6/9/16 at 9:21 a.m. with the Consultant Pharmacist PP revealed that the manufactures recommendation is to rotate the site and not use the same site for fourteen (14) days. She revealed that the nurses should document the site on the MAR based upon the [MEDICATION NAME] Patch Site Rotation Schedule. She revealed that the patch should use all medication within the 24 hour timeframe. She was made aware of the resident having multiple patches on after the facility was made aware although she was not aware of the photographs. She has never had a resident with multiple patches on at the same time but feels the most likely side effect would be nausea and lethargy. She has been inservicing staff on proper use of medication patches since she became aware. The Hospital Records were obtained on 6/6/2016 directly from the hospital after the request was made. Record review of the emergency room Physician's report dated 4/7/16, which were obtained after exit from the facility, confirmed the resident had three (3) [MEDICATION NAME]es on her back dated 4/2, 4/4 and 4/6 in the ER room . The physician contacted Georgia Poison Control for guidance. Georgia Poison Control recommended removal of all [MEDICATION NAME] Patches. The Physician also noted the resident had a low Potassium level which was treated in the nursing home starting last night 4/6/16. The resident was also found to be hypertensive at this time. The Emergency Department Discharge Physician's report, on 4/10/16 at 13:14, reveals Notes: I saw and evaluated the patient independently and agree with the resident's history and physical, and exam except as edited: 68 y/o female, h/o (history of) [MEDICAL CONDITIONS] status [REDACTED]. Accompanied by son, who report slight cough for 2-3 days, as well as episodes of vomiting yesterday (has since resolved). Somnolent now, but awake and minimally conversant. Markedly hypertensive but otherwise without focal exam abnormality. Broad ddx but appears encephalopathic, no focal neuro deficits; of note, appears to have duplicate revastigmine patches on her body, which were removed-per poison center, these could be contributing to her symptoms. Will check broad workup including CT head, and will likely require admission. Review of the hospital discharge summary dated 4/20/16 revealed a [DIAGNOSES REDACTED]. The resident was found to have a UTI which was treated with a five (5) day course of [MEDICATION NAME]. The resident was discharged to another Nursing Home at the request of the family. Review of the Inservice Education Program Summary record form dated 4/12/16 indicated an in-service on [MEDICATION NAME] Patches was done by the facility. Review of Drugs.com on [MEDICATION NAME] Patch-FDA prescribing information, side effects and uses revealed under Warnings and Precautions Medication Errors resulting in Overdose: Medication errors with [MEDICATION NAME] Patch have resulted in serious adverse reactions; some cases have required hospitalization , and rarely, led to death. The majority of medication errors have involved not removing the old patch when putting on a new one and the use of multiple patches at one time. | 2019-06-01 |
| 4789 | PRUITTHEALTH - FAIRBURN | 115506 | 7560 BUTNER ROAD | FAIRBURN | GA | 30213 | 2016-06-09 | 281 | D | 1 | 0 | WGW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on complainant interview, staff interviews, and the facility Medication Administration Record [REDACTED]. Findings include: Resident E was admitted to the facility on [DATE] with multiple diagnosis, including: Weakness, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), high Cholesterol, [MEDICAL CONDITIONS], Dementia, Hypertension, Decreased appetite, [MEDICAL CONDITION] Ulcer, Chronic [MEDICAL CONDITION], Depression, Vascular Neurocognitive Disorder with Behavioral problems. The resident had a physician's orders [REDACTED]. Apply patch to skin every day. Remove old patch. Rotate site and do not repeat the site for fourteen (14) days. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Five day, Minimum Data Set ((MDS) dated [DATE], revealed in Section C: Cognitive Pattern as unable to complete due to impaired cognitive status. Section G: Functional Status, A-J the resident was assessed for extensive assist. Interview on 5/18/16 at 10:30 a.m. with the Complaint D revealed that he had no further complaints other than the ones already voiced. He revealed that he had concerns about all of the patches being left on resident E and not being changed. He revealed that the staff could not have been assessing the resident and leaving all the medicine patches on her. Interview on 5/18/16 at 2:35 p.m. with Licensed Practical Nurse (LPN) BB of the 300 Hall revealed that she worked with resident E on (MONTH) 3rd, (YEAR). She revealed that she took off the old patch and put on a new one. She revealed that the old medication patch would have had a date of 4/2/16 written on it. She revealed that she had inservices on how to administer medication patches on (MONTH) 12, (YEAR). Interview on 5/18/16 at 3:15 p.m. with CNA EE of the 200 Hall revealed that she would report to the nurse if a resident have a lot of patches on. Interview on 5/19/16 at 9:15 a.m. with the Interim Administrator ZZ revealed that an investigation was completed on why the resident E had on extra patches. As a result, all nurses were inserviced on 4/12/16 and the sign in sheet was provided. Interview on 5/19/16 at 9:30 a.m. with LPN JJ by telephone revealed that she put the (MONTH) 6, (YEAR) patch on. She revealed that she removed a patch before she put the new one on. She revealed that she did not check the resident's whole body for any patches. She revealed that she had never put any patches any other place other than the resident's back and arm. She revealed that she attended an in-service on [MEDICATION NAME]es. Interview on 5/19/16 at 9:43 a.m. with LPN KK by telephone revealed that she worked the 11-7 shift. She revealed that she put on one (1) patch and remove the other patch. She revealed that the patch was scheduled for 6 a.m. in the morning; but, it was usually given at 9 a.m. rather than the scheduled time. She revealed that she has had an in-service on the [MEDICATION NAME] Patch. She revealed that her main responsibly for residents with patches, is to look at the whole body. Interview on 5/19/16 at 10:00 a.m. with LPN LL by telephone revealed that she looked for another patch on resident E. She revealed that she took off one (1) patch and put on a new patch on. She revealed that she assumed that the patch should be put on the upper back. She revealed that she has had an inservice on the patch. Interview on 5/19/16 at 11:00 a.m. with the Nurse Practitioner (NP) revealed that the some side of effects [MEDICATION NAME] are gastro-intestinal disturbances, nausea, and vomiting and can cause fatigue. She revealed that the patches should have been removed; and that the resident should never have on more than one patch. Review on the Medication Administration Record [REDACTED]. Apply one (1) patch to skin every day. Remove old patch (rotate site & do not repeat site for 14 days). (For [MEDICATION NAME]). Further review indicated that patch was applied to resident E on (MONTH) 1,2,3,4,5, and 6 , (YEAR) and that the site area was demonstrated by the number 1-31 to correspond with the [MEDICATION NAME] Patch Rotation Schedule chart. Review of the United Pharmacy Services [MEDICATION NAME] Patch Site Rotation Schedule indicated all [MEDICATION NAME] Patches need to be removed after 24 hours and replaced by a new patch. It further indicated that it is important for healthcare professionals to instruct patients and caregivers on the proper use of the [MEDICATION NAME] and particularly that: only one (1) [MEDICATION NAME] should be applied per day to healthy skin on only one of the recommended locations: the upper or lower back, or upper arm or chest; the patch should be replaced by a new one after 24 hours/ and the previous day's patch must be removed before applying a new patch to a different skin location.; to help minimize skin irritation, application to the same skin location within 14 days should be avoided. It further indicated that the site for all [MEDICATION NAME] Patches needs to be recorded daily on the MAR. Review on the Medication Record Sheet for resident F indicated Rivastigmine DIS 9.5 mg/24. Apply 1 patch to skin every day, Remove old patch (rotate site & do not repeat site for 14 days) For: [MEDICATION NAME]. At 9 a.m Review of the Medication Administration: [MEDICATION NAME] Drug Delivery System (PATCH) Policy: When administering medication via [MEDICATION NAME], nurses will follow current standards of practice to facilitate continuous medication absorption of the medication through the patient/resident's skin while the patch is in place. Nurses will provide proper care to the application site and application sites will be rotated per manufacturer's recommendations. Procedure and Key Points: #7. Observe site of previous patch application, gently remove old patch and dispose of according to health care center policy. #8. Select an appropriate site for application of new patch. Rotate site of application. Date and initial new patch before application. Review of the Inservice Education Program Summary record form dated 4/12/16 indicated an in-service on [MEDICATION NAME] Patches which was after the resident's admission to the hospital on [DATE]. Review of the State of Georgia Rules and Regulations for Standards of Practice for Licensed Practical Nurses (Rule 410-10-.02) (3) (a): Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment and other nursing services provided to the patient. | 2019-06-01 |
| 4060 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2017-04-17 | 323 | G | 1 | 0 | 74SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on electronic clinical record review, staff interviews, review of the facility policy titled, Fall Management, review of the facility forms titled, Incident Details reports, and review of the facility's Root Cause Analysis forms it was determined that the facility failed to re-evaluate the effectiveness of current fall protective measures and failed to implement Fall Prevention Protocol II, per facility policy, and put new measures in place to prevent additional falls for one Resident (R) (#1) who experienced seven falls in three months. This resulted in actual harm for R#1, who fell on [DATE], while ambulating and sustained a laceration to the back of the head which required transfer to the emergency room for treatment. The sample size was 3 residents with a history of falls. Findings include: Review of the facility's policy titled, Fall Management in pertinent part as specified in the Procedure section, that the resident will be considered high risk for falls if their total score on the fall risk assessment is 10 or above. If the score is 10-14, implement Protocol I which includes the following: Frequently orient and repetitively reinforce use of call bell and ensure it is within reach. Reassess for safe footwear, institute bowel and bladder routine as appropriate, conduct a medication review, evaluate the need for an adjustment in resident's daily activity schedule, educate resident's family regarding those interventions and encourage family assistance and support. If the score is 14-18, implement Protocol II, in addition to all interventions noted in Protocol 1. Fall Prevention Protocol II interventions to be intiated, in pertinent part: implement chair or bed alarm as appropriate, initiate half-hour hourly checks and/or placement of resident at nursing station, as needed. Implement use of protective equipment (helmets, hip pads), as indicated. Record review for R#1 revealed the resident had the following [DIAGNOSES REDACTED]. The facility had completed a Quarterly Minimum Data Set (MDS) assessment on 12/15/16. Section C- Cognitive Patterns documented that the resident as having severe cognitive impairment. Section G- Functional Status of this MDS documented that the resident was independent with walking/locomotion in the room and required supervision while walking in the corridor. Review of the Quarterly MDS assessment dated [DATE] revealed Section G- Functional Status, the resident required supervision with walking in corridor as well as locomotion on and off the unit. The facility Incident Details report documented that on 2/2/17 at 8:30 a.m., the resident was found on the floor in her room. Nursing staff noted that there were no apparent injuries. The Incident Details report further noted to continue to monitor for any complaints of pain. Further review revealed that there was not any documentation in the section titled Details of Corrective Measures Taken by Facility. The facility Incident Details report documented that on 2/7/17 at 11:30 a.m., the resident was found on the floor in the dining room with no apparent injuries. The Corrective Actions section of the report documented, unable to redirect because she is combative. The facility completed a Fall Risk Assessment for the resident on 2/3/17 and 2/8/17 with a score of twelve (12) which indicated that the resident was at risk for falls. Review of the 2/2/17 Physical Therapy (PT) screen noted the Registered Nurse reports a decrease in mental status and needs careful monitoring to prevent falls or dangerous behavior. Review of the 2/9/17 PT screen revealed documentation that PT was unable to make recommendations to address the falls from a skilled PT intervention. The facility Incident Details report and the Progress Notes documented that on 2/14/17 at 8:20 p.m., revealed that the resident was ambulating through the dining room with an unsteady gait. The resident fell against the corner of the wall and hit head. The resident had a small opening to back of head to the right side. The physician was notified and the resident was sent to the emergency room and received four staples to the area. Further review revealed that the resident was admitted to the hospital for closer observation and returned to the facility on [DATE]. The facility completed a Fall Risk Assessments on 2/28/17 and scored the resident as an 18 which indicated that the Fall Prevention Protocol II should have been implemented according to the facility's policy titled, Fall Management which documented that the facility should implement interventions which included, but were not limited to, implement chair or bed alarm, as appropriate, initiate half-hour hourly checks and/or placement of resident at nursing station, as needed, implement use of protective equipment (helmets, hip pads), as indicated. Review of the facility Incident Details report documented that on 3/30/17 at 4:30 p.m. that the resident fell while ambulating and sustained a skin tear to the right hand. There was no documentation in the section titled Details of Corrective Measures Taken by Facility. The facility completed a Fall Risk Assessment on 4/3/17 and scored the resident at a 15 which again indicated the Fall Prevention Protocol II should have been implemented according to the facility's policy titled, Fall Management. The facility Incident Details report documented that on 4/14/17 at 3:20 p.m. a visitor reported seeing resident on the floor in the lobby. The resident was disoriented and sitting up on floor with only socks on, took shoes off. No apparent injuries. Will continue to monitor. Further review revealed that there was not any documentation in the Corrective Measures section of the report. The facility Incident Details report documented that on 4/16/17 at 8:45 a.m., the resident was found on the floor next to bed with legs crossed. Noted with no socks or shoes on. No apparent injuries. Corrective measures taken were skid free socks applied and the resident in dining room with staff. The facility Incident Details report documented that on 4/17/17 at 10:05 a.m., the resident was noted by the certified nursing assistant (CNA) in the solarium staggering and fell to floor on bottom. Resident noted with skid free socks on. No apparent injuries. The Corrective measures section of this report documented that staff assisted from floor to chair in solarium for supervision per staff. It further noted that the resident was assisted to the dining room in a Geri- chair recliner for closer supervision per staff. During an interview with the MDS nurse Registered Nurse CC, and the Assistant Director of Nursing (ADON) on 4/17/17 at 10:45 a.m., revealed that there were not any new interventions to the falls care plan after the 2/2/17 and 2/7/17 falls. Further interview revealed that the only new intervention put in place after the 2/14/17 fall was: gather information on past falls and attempt to determine the cause of falls and to anticipate and intervene to prevent future recurrence. The MDS nurse Registered Nurse CC also confirmed that the care plan was not revised to include the Fall Prevention Protocol II to include half-hour hourly checks and/or placement of resident at the nursing station. She stated that she was not sure if staff knew to check on resident every half hour. Review of the Root Cause Analysis forms dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed that an analysis was conducted for R#1 and that the (MONTH) (YEAR) analysis revealed that the contributing factor for the resident's falls was the resident's cognitive status. The (MONTH) (YEAR) Root Cause Analysis revealed that the contributing factors for the residents falls was the residents cognitive status with resolutions/corrective actions noted to be, close observation by staff. During an interview with Licensed Practical Nurse (LPN) AA on 4/17/17 at 12:45 p.m., revealed that she has to check on the resident every two hours. She also stated that when they bring the resident to the nursing station, that the resident won't stay there. During an interview with Certified Nursing Assistant (CNA) BB on 4/17/17 at 1:15 p.m., she revealed that she tries to check on the resident every hour or every chance she gets. Despite the resident experiencing multiple falls, there was not any indication that the facility had re-evaluated the effectiveness of the fall interventions and there was not any indication that the facility put any new measures in place to prevent falls. There was also not any indication that after the resident was assessed to be an 18 on the 2/28/17 Fall Risk Assessment and assessed to be a 15 on 4/3/17 Fall Risk Assessment, that the facility implemented the Fall Prevention Protocol II, per facility policy, that included every half-hour checks and/or placement of the resident at the nursing station as needed or implemented the use of protective equipment (helmets, hip pads), as indicated. | 2020-08-01 |
| 4059 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2017-04-17 | 280 | G | 1 | 0 | 74SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on electronic clinical record review, staff interviews, review of the facility's policy titled, Fall Management and review of the facility forms titled, Incident Details report the facility failed to evaluate and revise the care plan interventions and/or determine the need to identify additional approaches for fall prevention for one (1) resident (R) (#1) who had been assessed to be at risk for falls and who sustained additional falls. This resulted in actual harm for R #1 when the resident experienced a subsequent fall and sustained a laceration to the head. The sample size was 3 residents with history of falls. Findings include: Review of the facility's Policy titled, Fall Management revealed, in pertinent part, the policy was to establish criteria for the identification of residents who are at a higher risks for falls/injury, to be utilized by Nursing Staff to help prevent falls and subsequent injury related to falls. Further review revealed that, all potential safety problems should be identified and included in the resident's plan of care. If resident has other falls, has repeated falls or falls with injury, Fall Prevention protocol will be implemented. Record review for R#1 revealed that the [DIAGNOSES REDACTED]. The facility had completed a Quarterly Minimum Data Set (MDS) assessment on 12/15/16. Section C- Cognitive Patterns documented the resident as having severe cognitive impairment. Section G- Functional Status of this MDS documented that the resident was independent with walking/locomotion in the room and required supervision while walking in the corridor. The resident had a care plan start date of 2/2/17 for being at risk for falls related to impaired cognition and short/long term memory problems. It noted that the resident was found on floor on 2/2/17. The care plan approaches included: be sure call light is within reach and encourage to use for assistance as needed, respond promptly to all requests for assistance, bed in lowest locked position at all times, coordinate with appropriate staff to ensure a safe environment, ensure resident is wearing appropriate footwear when ambulating or up in wheelchair, keep floors even and free from spills or clutter, notify MD and family members of fall, provide activities that minimize the potential for falls while providing diversion and distraction, Physical Therapy (PT)/Occupational Therapy (OT) evaluation and treat as ordered and use adequate, glare-free light. The facility Incident Details report documented that on 2/2/17 at 8:30 a.m. the resident was found on the floor in her room. The facility Incident Details report documented that on 2/7/17 at 11:30 a.m., the resident was found on the floor in the dining room with no apparent injuries. The facility Incident Details report and the Progress Notes documented that on 2/14/17 at 8:20 p.m., revealed that the resident was ambulating through the dining room with an unsteady gait. The resident fell against the corner of the wall and hit head. The resident had a small opening to back of head to the right side. The physician was notified and the resident was sent to the emergency room and received four staples to the area. Further review revealed that the resident was admitted to the hospital for closer observation and returned to the facility on [DATE]. Review of the resident's care plan revealed an entry of 2/14/17 which documented the resident's fall of that date, as noted on the 2/14/17 Incident Details report referenced above. However, further review of this care plan revealed that there was not any evidence to indicate that the facility reviewed the care plan to evaluate the care plan approaches listed above, which existed prior to the resident's fall on 2/7/17, were effective and there was not any evidence that the facility attempted to determine if additional interventions were needed to address the residents fall potential to prevent future falls. The only care plan documentation for 2/14/17 was to gather information on past falls and attempt to determine cause of falls and anticipate and intervene to prevent future recurrence. Further review revealed that the facility Incident Details report documented that on 3/30/17 at 4:30 p.m., the resident fell while ambulating and sustained a skin tear to the right hand. Review of the resident's care plan revealed an entry of 3/30 /17 which documented that the resident's fall on that date, as noted on the 3/30/17 Incident Details report referenced above. However, further review of this care plan revealed that there was not any evidence to indicate that the facility reviewed the care plan to evaluate the care plan approaches listed above, which existed prior to the resident's fall on 3/30/17, were effective and there was not any evidence that the facility attempted to determine if additional interventions were needed to address the residents fall potential to prevent future falls. Further review of the facility Incident Details reports revealed that on 4/14/17 at 3:20 p.m. a visitor reported seeing R#1 on the floor in the lobby. The resident was disoriented and sitting up on floor with only socks on, took shoes off. On 4/16/17 at 8:45 a.m., R#1 was found on the floor next to bed with legs crossed. Noted with no socks or shoes on. No apparent injuries. On 4/17/17 at 10:05 a.m., R#1 was noted by the certified nursing assistant (CNA) in the solarium staggering and fell to floor on bottom. Resident noted with skid free socks on. No apparent injuries. During an interview with MDS nurse Registered Nurse CC, and the Assistant Director of Nursing (ADON) on 4/17/17 at 10:45 a.m., revealed that there were not any new interventions to the falls care plan after the 2/2/17 and 2/7/17 falls. She further revealed that the only new intervention put in place after the 2/14/17 fall was: gather information on past falls and attempt to determine cause of falls and to anticipate and intervene to prevent future recurrence. The MDS Registered Nurse CC also confirmed that the care plan was not revised to include the Fall Prevention Protocol II to include half-hour hourly checks and/or placement of resident at the nursing station. Despite the resident experiencing multiple falls, there was no indication that the facility had re-evaluated the appropriateness of the care plan interventions pertaining to falls. Cross refer to F323 | 2020-08-01 |
| 2516 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2018-09-27 | 684 | E | 1 | 1 | KB6111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, clinical record review, observations, and staff interviews, the facility failed to ensure three (R#14, R#74, and R#197) received appropriate services to ensure their highest practicable physical well-being. Specifically, R#14 was not treated in a timely manner for a broken leg, R#74 did not receive timely treatment for [REDACTED].#197 was not assessed prior to being moved after a fall. The findings include: 1. The facility's policies related to a resident change of condition were requested from the Director of Nursing (DON) on 9/27/18 at approximately 2:30 p.m. The DON stated that she was not able to locate any such policies. R#14 was admitted to the facility on [DATE] with diagnoses, according to the Admission Record dated 9/26/18, including heart failure and hypertension. A Risk Management System Report, dated 8/29/18 noted, Resident stated that another resident accidentally hit her left foot with a power chair at 200-hall nurses' station. Resident verbalized pain to left extremity. Warm to touch. Color consistent to ethnicity. Resident assisted to bed. Minimal movement to left leg. The report indicated the resident's physician was notified of the incident. The Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 6/23/18, indicated R#14 was cognitively intact (the Brief Interview for Mental Status (BIMS) test score was 15/15), and the resident was totally dependent upon one to two staff members to complete most of her Activities of Daily Living (ADLs), including transfers. The assessment indicated the resident was independent with ambulation after being transferred to her power wheelchair. In addition, the assessment indicated the resident had limited range of motion to her upper and lower extremities on one side of her body. The ADL (Activates of Daily Living) Care Plan, dated 9/14/18, read: Focus: Resident requires assistance for ADLs; and Goal: Resident's ADL care needs will be anticipated and met through next review. Interventions included: Monitor for complications of immobility. No care plan could be found in the resident's record to indicate an injury to the resident's left foot. The Order Recap Report, dated 8/29/18 - 8/30/18 was reviewed and indicated an order for [REDACTED]. An X-Ray Report, dated 8/30/18 read: Reason for Study: Pain in left foot. Results: There is a displaced [MEDICAL CONDITION] tibial shaft. Conclusion: Acute displaced fracture of distal tibial shaft. The Order Recap Report, dated 8/29/18 - 8/30/18 was reviewed and indicated an order for [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED].>The Medication Administration Record [REDACTED]. On 9/15/18, the [MEDICATION NAME] order returned to the original 220 mg twice daily as needed The MAR indicated [REDACTED]. The record indicated R#14 received the Tylenol on 9/2/18 for a pain level of 4/10, on 9/3/18 for a pain level of 4/10, on 9/5/18 for a pain level of 4/10, and on 9/7/18 for a pain level of 3/10. A Change of Condition Note, dated 8/29/18 at 8:33 p.m., Note: A change in condition has been noted. The symptoms include: Other change in condition (left foot pain) on 8/29/2018 in the afternoon. Change reported to Primary Care Clinician on 8/29/2018 at 7:00 p.m. Orders obtained include: x-ray to left foot. Medicate for pain PRN (as needed) and as ordered. Continue to monitor. MD (Medical Doctor) will come see the resident. Caution while moving left lower extremity. A Nurses Note, dated 8/29/18 at 10:00 p.m. revealed R#14, Sustained left foot injury after another resident accidentally hit her with power chair. MD notified. New order for x-ray obtained. A physician progress notes [REDACTED]. History of Present Illness: [AGE] year-old female who is reporting pain to the left foot which she reports that it started yesterday after an incident involving another patient with a motorized wheelchair. X-ray of the left LE (lower extremity) shows displaced [MEDICAL CONDITION] tibial shaft. No [MEDICAL CONDITION] or toe. Patient reports effective results with current pain management, instructed patient to notify nursing staff if current plan is no longer effective. Patient's history is also significant for Vit (Vitamin) D deficiency which may make her more prone to fractures. Diagnosis, Assessment and Plan: Pain of left lower extremity. Will order ortho consult following x-ray results showing displaced [MEDICAL CONDITION] tibial shaft. Continue [MEDICATION NAME] and Tylenol as ordered for pain. A Nurses Note, dated 8/30/2018 at 8:15 a.m. read, x-ray to left foot done, resident tolerated well, denies pain or discomfort. Will continue to monitor. A Nurses Note, dated 8/30/18 at 10:30 a.m. read, This is a follow-up note from the change in condition-medical that occurred on 8/30/2018. Resident complained of pain to left foot. NP (Nurse Practitioner) in and copy of X-ray viewed and results indicate a fracture of distal tibial shaft. A Nurses Note, dated 9/1/18 at 12:30 p.m. read This is a follow-up note from the change in condition-medical that occurred on 08/29/2018. Resident given [MEDICATION NAME] 220 mg (milligrams) for pain. No further complaints voiced. A Nurses Note, dated 9/2/18 at 12:30 p.m. read, This is a follow-up note from the change in condition-medical that occurred on 08/29/2018. Resident alert and in no acute distress. Medicated with Tylenol 650Mg and [MEDICATION NAME] 220 mg for pain with effective results. A Nurses Note, dated 9/2/18 at 2:30 p.m. read, , Resident received [MEDICATION NAME] 220 mg and Tylenol 325 mg 2 tablets for pain with effective results. A Nurses Note, dated 9/2/18 at 10:30 p.m. read, , Resident continues to receive [MEDICATION NAME] for pain as needed. A Physician's Progress Note, dated 9/4/18 at 12:00 a.m., Chief Complaint / Nature of Presenting Problem: Left foot pain- patient is requesting some ice for her leg. History of Present Illness: [AGE] year-old female (resident) lying in bed and in no acute distress. Charge nurse reports that (resident) is requesting some ice for her left leg and that patient's niece wanted a second opinion in regards to LLE (left lower extremity) fracture/ displaced [MEDICAL CONDITION] tibial shaft. Discussed scheduling [MEDICATION NAME] for 7 days and then going back to previous schedule. Educated (resident) that ice is usually effective within the first 24-48 hours after an injury. Also reminded patient of the referral for orthopedics. Will schedule [MEDICATION NAME] Q (every) 12 HRS (hours) X7 days and then return to PRN (as needed) schedule, follow up with ortho a previously ordered for displaced [MEDICAL CONDITION] tibial shaft. Pain medication as ordered. No Progress notes could be found in the clinical record to address the resident's leg fracture between 9/4/18 and 9/25/18. A Nurses Note, dated 9/25/2018 at 11:19 a.m. read, , Late Entry: Resident went to the scheduled appointment for orthopedic consult via stretcher transport. Resident was not seen at the appointment: Orthopedist needed the transport to stay with the resident until she could be seen. Consequently, the resident was not seen. Grady was contacted for an appointment to follow up using stretcher transportation. Awaiting an appointment with Grady for orthopedic follow up. Niece is notified. A Nurses Note, dated 9/25/2018 at 12:00 p.m. read, , Late Entry: Note: (R#14) had a planned transfer. planned testing. A Nurses Note, dated 9/25/2018 at 2:56 p.m., Resident is transported to (Hospital) emergency room for orthopedic consult via stretcher (Ambulance Service) at approximately 1:45 p.m. Awaiting return and follow up orders. A Nurses Note, dated 9/26/2018 at 7:42 a.m. read, , Resident is admitted to Hospital unit 6[NAME] Per nursing report closed reduction and splinting was done. Call placed to niece and message left regarding resident's admission to the hospital. No Nursing Assessments could be found related to the resident's broken left lower extremity in the clinical record. During an interview with the Director of Nursing (DON) in her office on 9/26/18 at 10:51 a.m., she stated, (R#14) was not seen by the orthopedic physician due to someone could not stay with her on stretcher. The original appointment was on the 13th. Medical Records Manager (BB) makes all of the appointments. The DON indicated she did not know why it had taken so long to get R#14 in to see an orthopedic physician after her leg was broken. During an interview with Unit Manager (UM) AA in the conference room on 9/26/18 at 10:58 a.m., she stated, We had sent her out for an ortho consult prior to now. She has to go via stretcher, so when she got to the appointment the transport company could not stay with her and they refused to leave their stretcher at the office, so we tried to get her another appointment at (the Hospital) to be seen. No other office would accommodate her. We called the (Hospital) initially a day or so ago. We were trying to find out when an ortho (orthopedic physician) was going to be in the ER (emergency room ) to see her. We finally were able to coordinate an ortho in the ER last night. We've been trying to address the situation. She had a distal tibial fracture. She continued to have pain so the Nurse Practitioner (NP) ordered her pain meds, and nothing was resolved. During an interview with Medical Records Director (MRD) BB in the conference room on 9/26/18 at 11:04 a.m., she stated, R#14 originally went to an orthopedic clinic on 9/13/18, but the clinic would not see the resident because she arrived there on a stretcher. On 9/14/18, the hospital said they would take her via stretcher as long as there was an order for [REDACTED].#14 was sent to the ER (emergency room ) to be seen for her injured foot. During an interview with R#14 after her return from the hospital in her room on 9/27/18 at 12:18 p.m., she stated, I have a splint all the way up to my knee now. They put it on me at the hospital. That doctor over there asked me 'Why are they just sending you over here now if this break happened almost a month ago?' He said that to me. I told him I don't know. That's a good question. I had pain in my leg the whole time after the break. It's better now that it's splinted. The resident's left lower leg was observed to have a splint in place. During an interview with the Nurse Practitioner (NP) on 9/27/18 at 12:45 p.m., she stated she was aware of the resident's broken leg. She said she found out when reading the 24- hour report when it first occurred and the nurse told her the injury involved the resident's leg. The NP said she ordered x-rays. The NP further stated the following: At first, we increased her [MEDICATION NAME] to a scheduled dose .220mg twice a day for 7 days. She was taking it as needed before that. The same week the nurse told me that she was requesting some ice for the leg. I saw her again and told her ice doesn't really treat fracture after the firs 24 to 48 hours. They (nursing) told me they were scheduling the orthopedic appointment. She was not in distress at that time. (That day) I increased the [MEDICATION NAME] to 550 MG every 12 hours for the next 7 days. I also asked her if I could order her some [MEDICATION NAME] and she said no. She doesn't want to take strong medication. She (R#14) doesn't like narcotics. I do understand the concern about the delay in her appointment. If a patient isn't seen as scheduled, they (nursing) should communicate to me and they did not. I didn't find out that she hadn't been seen (by an orthopedic doctor) until Monday (9/24/18). I thought she had been seen. If I had known she had not been seen as scheduled I would have been able to evaluate the situation and said, (R#14) do you want to go out to the hospital? Do you want more pain medicine? Etc. They (nursing staff) put me a difficult situation. If they don't tell me what is going on, I don't know. I saw her today and they put the splint on her at the hospital. She says she's comfortable now. 2. The facility's Skin Integrity Management Policy, dated 11/28/16, read, The implementation of an individual (patient's skin integrity management occurs within the care delivery process. Staff continually observed and monitors patients for changes and implements revisions to the plan of care as needed; and Purpose: to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds; and Implement skin/wound care guidelines as applicable. R#74 was admitted to the facility on [DATE] with diagnoses, according to the Admission Record dated 9/26/18, including [MEDICAL CONDITION]'s Disease and movement disorder. The Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 8/18/18, indicated R#74 was severely cognitively impaired (the Brief Interview for Mental Status (BIMS) test could not be done due to the resident's severe cognitive impairment) and the resident was dependent upon one to two staff members to complete all of his Activities of Daily Living (ALs). In addition, the assessment indicated the resident did not have any pressure or non-pressure wounds on his body at the time of the assessment. The Skin Care Plan, dated 9/21/17, read, , Focus: Resident is at risk for skin breakdown r/t (related to) cognitive deficits, uncontrollable movements due to [MEDICAL CONDITION]'s Disease; and Goal: The resident will not show signs of skin breakdown through next review. Interventions included, apply barrier cream with each cleansing, assess/remind the resident to reposition as needed, observe skin condition with ADL care daily and report abnormalities, and weekly skin assessment by licensed nurse. The most recent Braden Scale for Predicting Pressure Sore Risk, dated 5/4/18, revealed a score of 12, indicating R#74 was at high risk for developing pressure sores. The Medication Review Report, dated 9/18, indicated no current orders for wound care. The Medication/Treatment Administration Records, dated 9/18 were reviewed and indicated no treatments were being received for wound care or skin maintenance. Skin Check Records for R#74, completed by the licensed nurse and dated 8/7/18, 8/10/18, 8/17/18, 8/24/18, 8/31/18, 9/7/18, 9/14/18, and 9/21/18 were reviewed and indicated no skin injuries or pressure areas were present on the resident's body. ADL Records, dated 6/18 through 9/18 were reviewed, and indicated R#74 was receiving baths/showers at least twice weekly as scheduled. Only one Bath Record Skin Audit was found for the reviewed date range of 6/1/18 through 9/26/18. The skin audit was dated 6/19/18, ad indicated the resident had an open area to his right lower extremity at the time of the audit. The nurse signature and date section on the audit was blank. R#74 was observed, lying in his bed on 9/24/18 at 10:43 a.m. An open area to the resident's right shin under his knee was observed. The open area was round and appeared to be approximately the size of a quarter. A second circular open area was observed below the first open area and appeared to be approximately 0.5 centimeters around. R#74 was observed, lying in his bed on 9/25/18 9:44 a.m. The open areas on the resident's lower right extremity remained as observed above. R#74 was observed lying in his bed on 9/26/18 at 8:19 a.m. The open areas on the resident's right lower extremity remained as observed above. During an interview with Certified Nursing Assistant (CNA) EE in the resident's room on 9/26/18 at 8:30 a.m., he stated, I personally don't document the skin stuff. (R#74) has involuntary movements. He can't control his movements and he bumps into things. We use ointment and barrier cream on his skin. CNA EE indicated he had not noticed the open areas on R#74's lower right extremity. During an interview with (CNA) DD on the 200 Hallway on 9/26/18 at 9:19 a.m., she stated she worked with R#74 on a full-time basis, and she stated, The last skin issue I reported (for R#74) was when he hit his shin on the geri-chair and broke it (the chair) last month. CNA DD said she hadn't noticed any other skin issues for R#74 and said she. reports to the nurse when I see something. During an interview with Licensed Practical Nurse (LPN) GG on 9/26/18 at 8:32 a.m., she stated, He (R#74) doesn't have any skin treatments. There is nothing on the Treatment Record. The surveyor observed R#74's skin with LPN GG, and she stated, (R#74) just gets A and D Ointment. He doesn't have any treatment orders. He kicked the hinges off his geri-chair last week. That's what happened (to his right lower extremity). During an interview with the Director of Nursing (DON) on 9/26/18 at 8:38 a.m., she stated, As far as I know (R#74) just has abrasion on his knee. It looks to be healed (according to the documentation in the record). I don't see any other open areas (in the documentation in the record). During an observation conducted with the DON present, R#74 was observed lying in his bed, on 9/26/18 at 8:39 a.m. The DON stated, the open areas on the resident's right lower extremity look like they are re-opened areas. I'll get with the nurse. Triple antibiotic should be on there. The last time I saw (the area) it was scabbed. It's re-opened. The DON said the CNAs and nurses look at residents' skin and report any findings. During an interview with Unit Manager (UM) AA in the nurse's station on 09/26/18 at 8:42 a.m., she stated, I was not told of (R#74's) re-opened area (on his right lower extremity). I should have been told. During an interview with UM AA in the Nurse's Station on 9/26/18 at 08:44 a.m., she indicated she was unable to find bath skin records for R#74 in the bath book (other than the bath skin sheet dated 6/19/18 referred to above). She stated, R#74 should be getting baths twice per week at a minimum, and a bath skin sheet should be done with each bath. The CNA's are supposed to give the bath skin sheet to me so that I can track any skin concerns. UM AA acknowledged that this had not happened for R#74 with regards to the open area on his right lower extremity. 3. Review of R#197's clinical record revealed the resident was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of R#197's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. According to the MDS, R#197 was independent with bed mobility, transfers, walking in the room/corridor, locomotion on the unit, toileting and hygiene. R#197 was steady at all times when moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers. R#197 was not steady but able to stabilize without the assistance of staff when walking (with assistive device if used) and when turning around and facing the opposite direction while walking. The resident had no impairment of upper and lower extremities and utilized a walker for mobility. The resident had at least one (1) fall within the prior 2-6 months prior to admission. The fall(s) did not result in a fracture. Review of R#197's care plan dated 6/12/18) revealed the following: Focus: Resident is dependent for ADL (activities of daily living) care in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Chronic disease. Interventions: Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted; Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects; Monitor laboratory test results and report abnormal results to physician/mid-level practitioner; Monitor for complications of immobility; provide cueing for safety and sequencing to maximize current level of function. Redirect resident to ambulate with walker; assist resident getting in and out of bed; and assist resident with ambulation. Focus: Resident is at risk for falls; unsteady mobility. Interventions: place call light within reach while in bed, or in close proximity to the bed; Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. Review of the Risk Management System report dated 7/3/18 revealed R#197 had an unwitnessed fall. LPN took the resident's vital signs post fall at 3:15 p.m. (Temperature - 98.6 degrees, Pulse - 91, Respirations - 20 and Blood pressure 151/74). The report noted the resident was transported to the hospital via ambulance at 10:30 p.m. The circumstances of the event were documented, as follows: Staff heard a noise in resident room and intervened to find her on the floor behind the door. She was lying flat on her back with her head pointing towards the foot of the bed. She was noted to have sustained an abrasion to her right index finger. No further injuries noted from the fall, right index finger cleaned, and band aid applied, resident denies pain. The root cause of the incident was noted to be ambulating without her walker. Interview on 9/25/18 at 12:09 p.m. with the Licensed Practical Nurse (LPN) JJ in the conference room revealed the resident had an unwitnessed fall, and she, another LPN and a CNA picked the resident up from the floor and placed her in her bed. LPN JJ stated at that time, she completed a head-to-toe assessment. The nurse said the only injury was to the resident's finger. LPN JJ could not provide a rationale for picking the resident up from the floor before assessing her for injury. LPN JJ stated she realized she should have assessed the resident for injury before moving her. Interview 9/25/18 at 12:50 a.m. with the facility's DON in the conference room revealed the facility's fall protocol instructed nursing staff to assess the resident before moving the resident or getting them up. It was the expectation for nursing staff to assess a resident on the floor before moving them to determine if there were any injuries. She said all nursing staff were trained to complete an assessment of a resident before moving them. | 2020-09-01 |
| 1024 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2019-08-23 | 580 | D | 1 | 1 | KYLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family (Responsible Party) and staff interview, record review, and facility policy titled Condition Change of a Resident, the facility failed to notify the family/representative (RP) of new medication orders and medication change orders of one resident (R)#102. The sample size was 62 Findings include: Review of the Admission record for R#102 revealed she was admitted with diagnoses, that include but not limited to; other [MEDICAL CONDITION], generalized anxiety disorder, hostility, [MEDICAL CONDITION] with behavioral disturbance, hypertension. Review of the Adminission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5, indicating severe cognitive impairment. Mood none. Behavior: verbal behavioral symptoms directed toward others. (threatening others, screaming at others, cursing at others). Functional status: needs extensive assistance in all areas. Bowel and Bladder: always incontinent of bowel and bladder. Record review of the Quarterly MDS dated [DATE] revealed a BIMS of 5, indicated severe cognitive impairment. Mood none. Behavior: none. Functional status: needs extensive assistance in all areas. An was assessed as receving an antidepressant on three out of seven days in this assessment period. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. An interview on 8/19/19 at 10:25 a.m. with the Responsible Party (RP) for R#102 revealed that the facility does not notify the family/responsible party (RP) of medication changes. An interview on 8/22/19 at 6:45 p.m. with Unit Manager (UM) G[NAME]confirmed that the was no documentation family/RP was notified of the medication changes for R#102. An interview on 8/22/19 at 6:54 p.m. with the Director of Nursing (DON) revealed that it is her expectations that the family be notified of changes in medication orders. | 2020-09-01 |
| 1572 | SUMMERHILL ELDERLIVING HOME & CARE | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2019-05-31 | 677 | D | 1 | 1 | U20X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family and staff interviews, and record review the facility failed to provide scheduled bath for one of 48 Resident (R#498) dependent on staff for activities of daily living (ADLs). Findings include: Review of the clinical record revealed R#498 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5/13/19 Admissions Minimum Data Set (MDS) revealed the resident was assessed as needing extensive assistance with dressing, personal hygiene, and toilet use. Review of the care plan revealed R#498 has an Activities of Daily Living (ADL) self-care performance deficit related to fatigue, recent rectal surgery, decreased mobility, and pain. Bathing/showering requires assistance by staff. R#498 should be provided a sponge bath when a full bath or shower cannot be tolerated. R#498 requires assistance by staff with personal hygiene and oral care. An interview with a family member of R#498 on 5/28/19 at 1:01 p.m., revealed that her father was in the facility for one week before receiving a bath. She stated he has not received any ADL care including, but not limited to, a haircut, cleaning of nails, and grooming of facial hair. During an interview on 5/30/19 at 12:05 p.m. with AA (RN Unit Manager). RN AA stated that R#498 is supposed to receive a bath on Tuesdays, Thursdays, and Saturdays. During baths he is supposed to be groomed. Review of an ADL task on Kardex revealed that the resident is to receive baths on Tuesdays, Thursdays, and Saturdays between the times of 11 p.m. to 7 a.m. R#498 received a bath on 5/19/19, 5/23/19, 5/24/19, 5/25/19, 5/26/19, 5/27/19, 5/30/19, and 5/31/19; however, the resident did not receive a bath until six days after being admitted to the facility. During an interview on 5/31/19 at 11:04 a.m. with the Assistant Director of Nursing (ADON) revealed that when a new admission comes into the facility the care information gathered during the initial assessment is entered into the Kardex and electronic health record. The ADON further revealed that Certified Nursing Assistants (CNAs) can see care information immediately and should begin care immediately. The ADON confirmed that R#498 did not receive a bath until six days after admission. Further interview with RN AA and ADON, at this time, revealed that the medical record for R#498, did not include any any documentation that indicated why the resident had not received a bath for the first six days after being admitted . | 2020-09-01 |
| 4136 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2017-03-08 | 490 | J | 1 | 0 | 03RZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family and staff interviews, record review and review of the facility's Policy and Procedure for Elopement, it was determined the facility failed to be administered in a manner to investigate an Elopement of one resident (R#1) as to the cause and to prevent the likelyhood of elopement for the additional ten (10) at risk residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) of a total of eleven residents with wandering behaviors and wearing a Wanderguard bracelet. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, the date a resident (R#1) wearing a Wanderguard, was found in the parking lot by staff on the 3:00 p.m. to 11:00 p.m. shift followed on 10/1/2017 when the resident eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 483.75(o)(1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans (F520 S/S: (J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician Orders were current and accurate and that care plans were updated for resident with wandering behaviors. Findings include: During a telephone interview with a family member of R#1 on 2/20/2017 at 5:00 p.m., the family member revealed that R#1 had eloped from the facility on 10/1/2016 and had fallen in the main road (Anderson Mill Road). R#1 had sustained a hematoma to the back of the resident's head and was transported to the emergency room for evaluation. The family member confirmed that R#1 was wearing a Wanderguard bracelet at the time of the elopement on 10/1/2016 and used a walker for ambulation. Review of the resident's care plan dated 3/15/2017 and revised on 2/20/2017 revealed the resident was care planned for wandering behaviors, confusion and for the use of a Wanderguard bracelet due to exit seeking behaviors. Additionally, the care plan revealed a focus note dated 9/28/2016 that the resident was noted in the parking lot. Returned to facility. Further review of the care plan for R#1 revealed that new interventions to prevent elopement were not put into place which is the date the Immediate Jeopardy began. An interview with the former Administrator on 2/20/2017 at 6:14 p.m. revealed that she was not aware of a resident with a Wanderguard leaving the facility on 10/1/2016 nor was she aware of R#1 being found in the parking lot on 9/28/2016. She looked at the resident's record, and stated that R#1 did leave from the facility on 10/1/2016 and fell in the street outside of the facility and had to be sent to the hospital. The Administrator further revealed that she is to be called, by staff, for any unusual incident within the facility and doesn't remember getting a phone call about R#1 eloping from the facility. The Administrator revealed that the facility has a morning meeting daily at 9:00 a.m. which she attends although she was not certain if she had attended the meeting on 10/1/2016 and that she was not aware of the resident's elopement. Review of the facility 24 hour reports for (MONTH) (YEAR) revealed there was no notation of the elopement of R#1 on 9/28/2016. Interview and observation of the door alarm system on 2/20/2017 at 6:30 p.m. with the former Maintenance Director (MD) EEE, revealed that she did not remember a resident eloping from the facility on 10/1/2016 or any resident eloping from the facility. Test by the MD EEE, and observed by the surveyor, of the main egress door indicated a chirping sound when the Wanderguard bracelet was near the door. All Wanderguards (11 residents) were checked at this time for functioning by MD EEE and all were functioning. Interview on 2/21/2017 at 3:41 p.m., by telephone, with Licensed Practical Nurse (LPN) FF revealed she was assigned to work on 200 and 400 Halls on the 11:00 p.m. to 7:00 a.m. shift on 9/30/2016 and R#1 was one her residents. She stated the resident was returned to her unit by Registered Nurse (RN) HH who stated that R#1had left the building and fell in the street, outside the facility, and was brought back in the facility in a wheelchair. She stated the resident was ok except for a bump on the back of her head. She stated the resident was sent out to the hospital for examination. LPN FF further revealed that she informed the doctor, the family member and the facility Administrator. LPN FF stated it took a minute to get in touch with the Administrator and she told the Administrator what had happen to the resident, the resident elopement and a bump to the back of R#1 head. She also told the Administrator the resident was sent to the hospital. LPN FF stated the Administrator thanked her for the information and stated that RN HH had already contacted her. She stated the Wanderguard was checked and it was working and that she conducted a neurological check on R#1 although she did not document it. She also stated the incident was recorded on the 24 Hour report. Interview on 2/21/2017 at 4:18 p.m. by telephone with Registered Nurse (RN) HH revealed she was assigned to 500 and 600 Halls on 9/30/16 and at around 6:30 a.m. on 10/1/2016 a housekeeper came into room [ROOM NUMBER] and told her a resident had fallen on the street outside of the facility. She stated she ran to the street and saw the resident on the sidewalk with her walker. She stated she assessed the resident and the Certified Nursing Assistant (CNA) brought a wheelchair outside and she placed R#1 in the wheelchair and returned her to LPN FF for further assessment. RN HH stated it was a very busy night and that she sent a text to the former Administrator with information about the night shift, including the elopement and the resident's name to the Administrator. She further revealed that the Administrator responded by saying what a busy night. Record review of the facility policy titled Resident Elopement Revised (MONTH) 2012 revealed: Policy: The facility strives to provide a safe environment and preventive measures for elopement. Personnel must report and investigate all reports of missing residents. Fundamental Information: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the DON and the Administrator and to document the occurrence. Procedure: Prevention, 1. Facility creates a photographic directory of residents identified at risk for elopement. a. Photograph residents identified at risk for elopement by the Nursing Admission Assessment upon admission. b. Store printed photographs, labeled with resident name and room number, in a binder. Multiple binders may be created if facility has multiple egress locations. Wander/Elopement Alarm Activation: 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm. b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement. c. If no resident is found to be exiting the facility, the employee should i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure all residents are accounted for. Attempted Elopement, 1. If an employee observes an attempted elopement, he or she should: a. Be courteous in preventing the departure and in returning the resident to the facility. b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the DON and the Administrator that a resident is attempting to leave the premises. 2. Upon return of the resident to the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (DON), b. Contract the attending physician, report what happened, and follow the physician's orders; c. Contact the resident's legal representative and inform them of the incident; d. Complete and file an Incident/Accident Report, (Briggs), e. Make appropriate notations in the resident's medical record (DON), f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventive interventions for elopement (DON). The facility could not produce evidence that the elopement of R#1 had been investigated prior to 2/20/2017, for either the 9/28/2016 or 10/1/2016 elopement, nor to determine the cause of the elopement or interventions to prevent the elopement of R#1 or the 10 residents with Wanderguard bracelets. Cross refer to F323 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/22/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 3. On 2/20/2017 at 8:00 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms and if the door alarmed, why and what action was taken. 4. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at[NAME]Mill as of 3/7/2017. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 3. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 4. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017, pending investigation of the 10/1/2016 Elopement of R#1. Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017. | 2020-03-01 |
| 4632 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2016-08-08 | 314 | D | 1 | 0 | S83P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, observation, record review and staff interview the facility failed to ensure that a pressure ulcer dressing for one (1) resident A was changed per physician orders [REDACTED]. The sample size was thirteen (13) residents. Findings include: Record review of the medical record for resident A revealed that the resident was admitted to the facility on [DATE], and was presently receiving [DEVICE] feedings, on a Ventilator, had a indwelling urinary catheter, assessed with [REDACTED]. During an interview with resident A's daughter on 8/07/2016, at 2:40 PM, the daughter informed this Surveyor that approximately 2:30 PM 8/07/2016, two (2) Certified Nursing Assistants (CNAs) came into the room to clean up the resident before the shift change was over. When the resident was turn to the side, the daughter asked that she wanted to see the wound and take a cell phone picture of the wound and dressing. The cell phone picture was taken by the family member. The daughter then proceeded to show the cell phone picture to the Surveyor and it showed a soiled dressing with stool on it. The daughter then informed the Surveyor that the CNAs never informed the nurses that the dressing was soiled and needed to be changed as no one ever came in the room to changed the soiled dressing on the sacral wound. An interview with the staff nurse CC on 8/07/2016 at 3:30 PM, revealed that no CNAs informed the staff nurses or treatment nurse that the sacral wound dressing for resident A was soiled and needed be changed. Record review of the pressure ulcer treatment orders for resident A revealed that the sacral pressure ulcer was to be cleaned with normal saline, then skin prep to be applied to the periwound, pack the wound with Mesalt, cover with a dry dressing and secure with tape. The dressing was to be changed daily and as needed (PRN). An interview with the CNA assigned to the resident on 8/8/2016 at 10:10 AM, revealed that she never informed the staff nurses or treatment nurse that the when she cleaned the resident up on 8/07/2016 before leaving for the shift change at 3:00 PM, she never informed any of the nurses that the sacral wound dressing was soiled with stool before leaving for the day. | 2019-08-01 |
| 925 | LIFE CARE CENTER OF GWINNETT | 115347 | 3850 SAFEHAVEN DRIVE | LAWRENCEVILLE | GA | 30044 | 2017-10-12 | 425 | D | 1 | 0 | GRKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, record review, review of the facility Physician order [REDACTED].#1) of three (3) sampled residents. Findings include: An interview with the Complainant and the Resident's (R1's) Responsible party on 10/12/17 at 12:05 p.m. revealed R1's family believes the facility abruptly stopped administering Zoloft to R1 as prescribed, causing her mental health to decline and her dementia worsen and caused her recent fall and subsequent injury because it made her dizzy. Review of the clinical record for Resident (R#1) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record Review revealed the resident had experienced a fall on 9/9/17 attempting to go to the toilet without assistance. The resident had sustained a laceration to her head requiring four staples to close to the wound. Review of the Physician order [REDACTED]. clarify and include in new order discontinuation of the existing order. Review of Physician orders [REDACTED]. Review of the Hospital discharge medicine list also revealed two orders for Sertraline 25mg 1 tablet by mouth daily. Further review of the physician's orders [REDACTED]. The order did not indicate that the order to discontinue was only for the duplicate order. An additional order dated 9/16/17 for Sertraline 25 mg tablet daily indicating the medication was resumed on 9/17/17. Review of the Medication Administration Record [REDACTED]. The order for Sertraline 25 mg one daily was not transcribed to the (MONTH) (YEAR) MAR until (MONTH) 17, (YEAR) indicating (R#1) did not receive medication as ordered by the Physician from (MONTH) 1, (YEAR)-September 16, (YEAR). Interview on 10/12/17 with Registered Nurse (RN)/Unit Manager HH revealed that R#1 was admitted to the facility with a prescription for Zoloft/Sertraline and another antidepressant medication. However, the hospital orders were duplicated in transcription, for Sertraline 25 mg one daily. The facility nurse reviewed the orders and intended to discontinue one of the orders because it was a duplicate. When we faxed it to the pharmacy, it was automatically discontinued and R#1 did not receive the Zoloft/Sertraline until the error was discovered. However, the resident did receive the Zoloft /Sertraline on 8/31/17.The order for Sertraline 25 mg tab by mouth at 9 a.m. for depression happened on time on 8/31/17 and resumed on 9/16/17 when the family asked if she was getting the medication. After this incident, the staff development nurse gave Licensed Practical Nurse LPN (II) training on how to transcribe when you have duplicate orders. I would expect my nurses to write that an order is duplicate on the orders if she was discontinuing a duplicate order. Interview on 10/12/17 at 5:21 p.m. with R#1's Physician revealed, the same way you can change one antidepressant to another, there is no detrimental effect for discontinuing Zoloft/Sertraline. It would not cause dizziness or disorientation. This is not a huge medical impact on the patient's quality of life causing major side effects. Interview on 10/12/17 at 5:51 p.m. with facility pharmacy consultant KK revealed if it's a high dose you would taper down over a few weeks to avoid side effects. R#1 was already a low dose and so it's hard to say it would contribute to a fall. I don't believe stopping a dose that low would be a factor. Interview on 10/12/17 at 6:35 p.m.-with Administrator-QA is monthly, and as needed and the medical director is there each meeting. We review all departments and we have a report from pharmacy. We have not had a QA meeting since this incident, if the nurses find an incident with a med error, the nurse's immediately educate. If there is a pattern, it's brought up in Q[NAME] I believe this incident was isolated. Things happen. We feel there is a process in place to make sure this does not happen again. We are going to put it in QA and address it in the next meeting. The nurses have monthly in-service meetings-this is not a pattern it was just a fluke but it is something we are keeping an eye on. We will be putting this in the QAPI. Interview 10/13/17 at 9:07 a.m. with the Dispensing Pharmacy General Manager revealed if the pharmacy receives an order to discontinue Zoloft/Sertraline, it will be discontinued off the profile. The system would have caught any duplication of the original orders and left only one (1) prescription if a duplicate order was submitted. The dispensing pharmacy encourages the facility to read through hospital orders and transcribe them before sending them to the dispensing pharmacy. On the dispensing pharmacy side, we would catch the duplicate and only fill it once. The facility should have just marked through the duplicate or discontinued the original order. It could be considered a documentation issue. The key is for the facility to review and transcribe orders and convert them to the dispensing pharmacy order sheet prior to submission, this is strongly encouraged, but not mandated. There is no way the pharmacist would question a discontinued order on the pharmacy side. We get a thousand discontinued orders a day. Sertraline is a common drug and it was ordered at a low dose, I can't see any pharmacy questioning the discharge of such a low dose of Sertraline. | 2020-09-01 |
| 4680 | PRUITTHEALTH - VIRGINIA PARK | 115531 | 1000 BRIARCLIFF ROAD NE | ATLANTA | GA | 30306 | 2016-08-24 | 514 | D | 1 | 0 | 3CUI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to maintain accurate and complete clinical records for 2 of 9 sampled residents (R108, R57). Findings include: 1. Review of the closed clinical record revealed Resident (R) 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R108 had 13 falls within one year. Review of the Care Plan dated 4/19/16 indicated R108 had interventions put in place after each of the falls. Review of 9 incident reports dated 2/02/16 through 4/19/16 revealed the staff did not document which interventions, if any, were in place at the time of R108's falls. During an interview on 8/23/16 at 8:08 a.m. the Treatment Nurse said she administered the first aid after R108's last fall. She said the nurses did not normally document which interventions were in place at the time of a resident's fall. During an interview on 8/23/16 at 8:45 a.m. the Director of Nursing (DON) said the nurses referred to the resident's care plan and the nurse aides referred to an activities of daily living (ADL) guide in order to know which interventions should be in place for that resident. The DON said the staff did not document in the incident report or in nurse's notes what interventions were in place at the time of a resident's fall. The DON said she could see how it would be beneficial to document the interventions in order to know if they were utilized and if they were effective or not. She said that was not the current procedure for the facility. 2. R57's record was reviewed on 8/22/16 at 11:05 a.m. R57's [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. Foley catheter care was to be completed every shift. Review of an Admission/Nursing Observation Form, dated 5/17/16, completed upon readmission to the facility, indicated Bladder Resident/Family reports: Brief (marked with an X) and Hx (History) of UTI (Urinary tract infection) Indwelling Catheter DX (diagnosis) HX UTI Size 16. R57 was observed on 8/23/16 at 9:00 a.m., during wound care with Licensed Practical Nurse (LPN) 18 and Nurse Aide (NA) 33 present, lying in bed. NA 33 and LPN 18 removed the resident's incontinence brief. The catheter was observed to be inserted into the resident's scrotum next to his penis. When asked, LPN 18 indicated she had not seen this before and this should have been reported to the nurse. She indicated the catheter was not in the resident's penis but was going through the area to the side of the penis. NA 33 indicated she had not seen where the catheter was inserted on the resident before now. Further review of the resident's record lacked documentation related the placement of the catheter (Cross Reference F315). R57's catheter was observed on 8/23/16 at 10:03 a.m., with the Director of Nursing (DON) present. The DON indicted a urologist had surgically inserted the catheter. She indicated she would have to look for documentation of the catheter. During an interview on 8/23/16 at 12:55 p.m., the DON indicated she was still looking for information for the resident's catheter. During an interview on 8/23/16 at 2:00 p.m., the DON indicated she was trying to get information from the hospital related to the catheter. She indicated the catheter had been surgically inserted when he was in the hospital before he had been readmitted to the facility on [DATE]. During an interview on 8/23/16 at 2:05 p.m., the Corporate Nurse Consultant indicated she was not sure what was going on with R57's catheter. She indicted it was not located in the normal place and she was not able to find any documentation in the resident's record related to the catheter location. | 2019-08-01 |
| 5078 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 315 | D | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to address a decline in urinary incontinence for one (1) resident (#237) from a total sample of thirty-seven (37) residents. Findings include: Resident #237 was admitted to the facility, on the Rehabilitation Unit, on 9/15/15 with [DIAGNOSES REDACTED]. Licensed nursing staff documented that the resident had frequent urinary incontinence on the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/22/15. The resident's urinary continence improved to only occasional urinary incontinence as documented on the 14 day MDS assessment (ARD of 9/27/15). On 10/12/15, the resident was transferred to a different unit in the facility. The resident's urinary continence declined to always incontinent as documented on the quarterly MDS assessment (ARD of 12/21/15). Licensed nursing staff developed a plan of care dated 9/30/15 that documented the resident had frequent episodes of bladder incontinence, occasional bowel incontinence and was at risk for altered skin integrity. On 12/23/15 update to the plan of care documented that the resident continued to be at risk for infection and altered skin integrity. However, the decline in urinary continence was not addressed. A review of the clinical record revealed no evidence that licensed nursing staff had developed and implemented interventions to address the resident's decline in urinary continence. During an interview on 1/7/16 at 9:47 a.m., Certified Nursing Assistant (CNA) OO stated that that resident #237 was incontinent and had been so since being transferred to the current unit of the facility. During an interview on 1/8/16 at 12:25 p.m., the Assistance Director of Nursing (ADON) confirmed that licensed nursing staff had not addressed the decline in urinary continence for resident #237. | 2019-01-01 |
| 5082 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 406 | D | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to maintain a Level II Preadmission Screening and Resident Review (PASRR) assessment for one (1) resident (#97) from a total sample of thirty-seven (37) residents. Findings include: Resident #97 had [DIAGNOSES REDACTED]. During an interview on 1/7/16 at 12:41 p.m. Social Service staff JJ confirmed and provided documentation that a Level II PASRR assessment had been completed for the resident on 4/1/2012 by Adult Protective Services (APS) Healthcare. However, she was unable to locate a copy of the assessment. There was no evidence the facility maintained a copy of the resident's Level II PASRR assessment. | 2019-01-01 |
| 5079 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 319 | D | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to obtain a Physician ordered consultation to address one (1) resident's (A) complaints of Hallucinations from a total sample of thirty-seven (37) residents. Findings include: Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Licensed nursing staff developed a plan of care on 9/16/15 that documented the resident was a new admission to the facility, had multiple medical problems, was alert and oriented and communicated without difficulty. The plan of care was updated on 11/3/15 with a new intervention for a Care Now consultation due to Audio-Visual Hallucinations. A review of the clinical record revealed an 11/2/15 nurse's note entry that documented the resident complained of hearing and seeing things and of waking him/herself up at night by talking in his/her sleep. A subsequent nurse's note on 11/3/15 documented that the Nurse Practitioner addressed the resident's concern of hearing and seeing things by ordering a Care Now consultation. The 11/3/15 order was for licensed nursing staff to obtain a Care Now consultation due to Audio-Visual Hallucinations. After 11/3/15, although there was no evidence the resident continued to experience Hallucinations, there was also no indication that licensed nursing staff had obtained the consultation as ordered. During an interview on 1/8/16 at 12:25 p.m. the Assistant Director of Nursing (ADON) confirmed that the resident had not received the 11/3/15 consultation to address Hallucinations as ordered. | 2019-01-01 |
| 1606 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2019-08-30 | 609 | D | 1 | 0 | QEF711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, review of a policy titled Abuse, Neglect and Exploitation the facility failed to notify the State Survey Agency (SSA) within the required two-hour time period after Resident (R) #1 sustained an injury of unknown source, a hematoma (bruise) on his forehead. This failure affected one resident (R#1) of three sampled residents. Findings include: Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#1 was admitted to the facility in the spring of 2019 and his [DIAGNOSES REDACTED]. Review of the 7/29/19 Quarterly Minimum Data Set, section C, revealed R#1's Brief Interview for Mental Status (BIMS) score to be three out of 15, signifying severe cognitive impairment. Review of section G revealed R#1 required extensive assistance for nearly all Activities of Daily Living (ADLs). Review of a 7/21/19 at 7:35 p.m. progress note revealed a large hematoma was noted on R#1's forehead, the previous shift denied knowledge of the injury, R#1 could not provide history of the hematoma, and the injury was unwitnessed. Review of the policy titled Abuse, Neglect and Exploitation, updated on 12/2017, revealed revealed Injuries of Unknown Source to be defined as the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. Further review revealed the definition to also include the injury was suspicious because of the extent of the injury or the location of the injury. Further review revealed an immediate investigation should take place when abuse is suspected, such as an injury of unknown origin. An interview with the Administrator on 8/29/19 at 2:40 p.m. revealed that she first became aware of R#1's injury of unknown origin to his forehead on 7/22/19, the day after it was first documented by the duty nurse. The Administrator stated all injuries of unknown origin must be reported to the SSA within two hours of discovery, with no exceptions. The Administrator stated the nurse did not report this injury to her when it occurred. The Administrator further revealed that she was the Abuse Coordinator for the facility. An interview with the Regional Nurse Consultant (RNC) on 8/29/19 at 3:00 p.m. revealed that he agreed that R#1's injury of unknown origin occurred on 7/21/19 at about 7:35 p.m. and was not reported to the SSA until the following day, outside the required two-hour time window for reporting injuries of unknown source to the SS[NAME] | 2020-09-01 |
| 3019 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2018-03-12 | 550 | D | 1 | 0 | W7TD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, review of the facility policy titled, Smoking, Residents and Employees the facility failed to ensure that smoking privledges were not restricted for one resident (#2) from a total sample of 11 residents. Findings include: The had a policy regarding smoking. The Smoking, Residents and Employees policy documented that all smoking equipment for residents would be left with the charge nurse and stored in a secured area. Smoking restrictions will not be placed on any resident for the convenience of the staff, but for the safety and well being of the resident. Based upon assessment a resident may be deemed at risk to self or others when smoking and therefore assessed to be unsafe to smoke. The nurse will make the appropriate documentation in the resident's clinical record and notify the responsible party and physician as necessary. The policy further documented that information regarding smoking priviledges, including restrictions, would be documented in the resident's care plan. Resident (R)#2 was admitted to the facility on [DATE]. The resident was evaluated and intially careplanned as being a smoker. There was no evidence on the smoking assessment or initial careplan of any smoking privileges restrictions. However, a review of the clinical record revealed nurses notes entries by Licensed Practical Nurse (LPN) AA on 2/11/18 and 2/23/18 that documented the resident was being restricted from smoking for being found with cigarettes. The 2/11/18 19:20 Behavior Note documented that the resident had been observed with two extra cigarettes he had on himself at the 7:00 p.m. smoke break and was informed that he would not be allowed to attend the next smoke break at 10:00 p.m. or the smoke break the next day on 2/12/18 at 6:00 a.m. The 2/23/18 22:05 Behavior note documented that the resident did not have any cigarettes in the basket (maintained by staff) but then pulled out two cigarettes he had on himself at the 10:00 p.m. smoke break. The note further documented that the resident was informed that he would not be allowed to attend the next smoke break on 2/24/18 at 6:00 a.m. During an interview and review of nurses notes on 3/8/18 at 1:04 p.m., the Director of Nursing stated that LPN AA should not have restricted R#2's smoking privileges. She stated that staff cannot deny residents a smoke break and that she was not aware of that occuring. | 2020-09-01 |
| 811 | PRUITTHEALTH - AUGUSTA | 115334 | 2541 MILLEDGEVILLE ROAD | AUGUSTA | GA | 30904 | 2017-06-16 | 309 | D | 1 | 0 | TF3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assure that one resident, Resident #1 (R#1) of the three sampled residents recieved physican ordered pain medications until five days after admission to the facility. Facility census was 83. Findings include: Resident #1 (R#1) admitted [DATE] with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A Pain Observation Form was completed on 6/12/2017 listing arthritis, [MEDICAL CONDITION], perineal and scrotal [MEDICAL CONDITION], shooting pain in legs, especially at night, discomfort to lower extremities, knees, and discomfort to buttocks. [MEDICATION NAME] 10/325 miligrams (mg) 1 by mouth every six hours as needed for pain. Review of the 'Admission Interim Care Plans Form' dated 6/12/2017 for R#1 revealed to 'administer pain medications per physician's orders [REDACTED]. Review of the out-patient medication orders, dated 6/9/2017 listed 23 active medications, including [MEDICATION NAME]-[MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg to be taken one tablet by mouth every six hours as needed for pain. Review of the 'physician's orders [REDACTED]. Review of the 'Medication Record' dated 6/9/2017 reveals that resident did not receive any [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] until 6/14/2017. Review of the 'Skilled Daily Nurses Note' dated 6/11/2017 at 5:00 a.m. reveals R#1 complained of lower limb pain and was given 650 mgs of Tylenol. Review of the 'Skilled Daily Nurses Note' dated 6/9/2017 reveals that [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] had not been brought by the pharmacy yet. R#1 had some relief. Intensity of the pain was rated a '10' on a scale of 0-10, with 0 being no pain and ten being the highest pain. R#1 was complaining of shooting pain at night in both legs. Review of the 'Skilled Daily Nurses Note' dated 6/14/2017 at 5:30 p.m. reveal complaint of right lower extremity pain, no intensity documented. [MEDICATION NAME] administered for pain. Review of faxed requests to R#1's facility physician reveals physician was not contacted until 6/12/2017 (no time available) with a request to send renewal forms for R#1's [MEDICATION NAME] 10/325mg 1 tablet by mouth every six hours. An 'Approved Prescription' was received on 6/13/2017 at 4:57 p.m. that reads '[MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg, Take 1 tablet(s) every 6 hours by oral route as directed for 30 days. Interview with the Director of Nursing (DON) on 6/16/2017 at 7:12 p.m. who states that the facility's physician was out of town at the time the resident was admitted and that the VAMC should have sent a written prescription with the resident for the [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME]. DON admits that no attempt was made to contact the on-call physician or call the VAMC for a prescription. Interview with the DON on 6/16/2017 at 9:05 p.m. who reveals that the on-call physician could have been contacted for a prescription and that there is no policy requirement that residents receiving narcotics must have a written prescription when admitted in order to receive narcotics. The DON futher reveals that the facility's physician will only write prescriptions for narcotics on Tuesdays and Fridays. Interview with R#1 on 6/16/2017 at 4:25 p.m. who reveals that he always has pain, but pain medications make the pain bearable. He requested pain medication the night he arrived but was told he did not have any yet. He asked again the following day when lunch was served and again that night. He was told by one of the nurses that he would not have a prescription until Tuesday because that's when the doctor wrote them. R#1 stated that he takes [MEDICATION NAME] for [MEDICAL CONDITION], and that staff gave him some Tylenol, but that was like drinking water, it didn't help. R#1 further states that he complained about pain every day. Interview with R#1 and FM AA on 6/16/2017 at 5:45 p.m. who reveal that resident always experiences some pain. AA reveals that she went to the nurse's station and asked for pain medication from staff and was told that resident needed a prescription from the doctor and they were attempting to get it. FM AA states that resident complained of pain everyday but all he received was Tylenol. | 2020-09-01 |
| 2995 | EAGLE HEALTH & REHABILITATION | 115618 | 405 S COLLEGE ST | STATESBORO | GA | 30458 | 2017-12-18 | 655 | D | 1 | 0 | OZA311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to develop a baseline care plan for one resident, Resident (R)#1, of five sampled residents. The baseline care plan did not include the minimum healthcare information necessary to properly care for the resident including services for transmission based precautions, Foley catheter care, gastrostomy tube ([DEVICE]) care and peripherally inserted central catheter (PICC) care. Findings include: Record review revealed that the resident was admitted to the facility on (MONTH) 16, (YEAR) then transferred on (MONTH) 27, (YEAR) to an acute care hospital at the request of the family. Review of the immediate (base) care plan, not dated, revealed there was no care planning to address the resident's ongoing infection with [MEDICAL CONDITION] (c. diff), Foley catheter, PICC line or gastrostomy tube as noted on R#1's discharge instructions dated (MONTH) 16, (YEAR) from her prior facility. Review of the R#1's 'Admission Assessment, dated (MONTH) 16, (YEAR), listed that resident was admitted with [DIAGNOSES REDACTED], a Foley catheter and a PICC line. Interview with the Wound Care Nurse, Licensed Practical Nurse (LPN) GG on 12/18/2017 at 12:30 p.m. who confirmed that resident's infection with [DIAGNOSES REDACTED] was on-going at the time off admission and that transmission based precautions were implemented on admission. LPN GG also confirmed that resident had a PICC line present in her right arm, a Foley catheter, and a [DEVICE], all present on admission. Interview with the of Director Nursing (DON) on 12/18/2017 at 4:35 p.m. who confirmed that resident was admitted with [DIAGNOSES REDACTED], a PICC line, a Foley catheter and a [DEVICE]. Review of the resident's base line care plan with the DON who agreed that R#1's care plan did not provide adequate information for addressing the resident's immediate needs and that Acute Care Plans should have been added for PICC line care, Foley catheter care, [DEVICE], and transmission based precautions to the residen't care plan. Post survey interview with the Infection Control nurse, LPN NN on 12/20/2017 at 10:35 a.m. revealed that R#1 was discussed in the morning meeting the day after R#1 was admitted . LPN NN stated that Infection Control policies are available at the nurse's stations, and staff are trained on the implementation of infection control measures. LPN NN further stated that R#1's medications and discharge planning from her previous facility was reviewed on admission and all transmission based precautions were implemented on admission. | 2020-09-01 |
| 4495 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 205 | D | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a bed hold notice was provided to 1 of 12 sampled residents (R12) and/or her responsible party upon transfer to a local hospital. Findings include: Closed record review for Resident (R)12 revealed the resident had a [DIAGNOSES REDACTED]. Review of the resident's computerized financial record revealed the resident failed to pay her patient liability owed to the facility for 3 consecutive months. On 8/29/16 at 2:25 p.m. during an interview with the Business Office Assistant (BOA), she reported she visited the resident in her room on 4/11/16 to issue the resident a 30 day discharge notice. The BOA said the resident refused to accept the paper notice, therefore, she left the notice on the resident's bed side table. Additionally, the BOA reported the contact number the facility had on record for the resident's responsible party, was no longer working. On 4/11/16 at 5:30 p.m. the closed record indicated the resident began yelling and was uncontrollable, therefore, she was sent out to the local hospital for treatment and medication management. The following day the local hospital notified the facility of the resident's status and anticipated transport back to the nursing center. At this time the facility denied R12's readmission for failure to pay. A current policy entitled Bed Hold Policy Requirement and Notification indicated if a resident is transferred out of the facility, the facility will provide written information about the facility's bed hold policy. The Social Service Director (SSD) was interviewed on 8/29/16 at 12:00 p.m. The SSD said no bed hold notice was given to, or sent out with, the transfer paperwork informing the resident of her rights. On 4/11/16 the resident was discharged from the facility according to the Business Office Assistant without any information regarding the facility's Bed Hold Policy. During an interview with the Administrator on 8/29/16 at 2:40 p.m., he confirmed the resident was issued a 30 day discharge notice for failure to pay, and even though R12 had not exhausted her 30 day notice and the facility did not inform the resident and/or her responsible party of the bed hold policy, she was not accepted back to the facility. | 2019-09-01 |
| 4375 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 323 | G | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a safe environment for three (3) residents (R15, R28 and R29). Specifically, the facility: a). failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. R15 sufferred actual harm when she fell again contributing to an additional hip fracture which led to her ultimate demise, and; b). failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip, this resulted in actual harm when the facility unplugged the pressure prevention mattress used for R28 who had severe pressure sores. (cross refer to F314) The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form 672, signed and dated on [DATE] by the Director of Nursing revealed a total of 10 residents ambulated, 3 ambulated with assistance, 2 are bedfast, and therefore at least a total of 97 residents are at fall risk. Findings include: 1. Review of the Transfer/ Discharge Report revealed R15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a fractured hip. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the hospital records [DATE] History and Physical revealed This patient is a very pleasant, [AGE] year-old with a known history of heart failure, chronic pain, neuropathy, spinal stenosis, and generalized debility, who apparently has been having pain in her right lower extremity for the past several days. According to her son, the R15 has not incurred any falls; however, he was informed last Thursday that the R15 had gently slumped to the ground. He states that ever since that time, she has been having severe right lower extremity pain. She has been working with physical therapy with regards to the pain, but it has not gotten any better. He reports that over the last couple of days, the mental status of R15 has somewhat declined and she has become a little bit more confused. This is usually indicative of a urinary tract infection and this prompted the nursing facility to send R15 to the emergency room , R15 underwent a workup, which revealed a distal femur fracture, as well as a urinary tract infection, acute kidney injury and hyperkalemia. Given these issues, the patient has been admitted for further evaluation and treatment. Review of the [DATE] nursing note for R15 documented at 7:25 a.m. revealed, on last rounds at about 6:50 am, assessment the right hip surgical site staples intact, moderate amount dark colored blood was observed sipping out from between the staples. The surgical site surrounding skin was also noted to be warm and tender to touch with slight discoloration. Resident c/o pain to area; Percocet ,[DATE] mg given and she was repositioned with assistance of another nurse for comfort; administered analgesic result pending. BLE (bilateral lower extremity) also remain edematous (non-pitting), both elevated on pillow and heels floated on pillow. No noted acute respiratory distress. O2 (oxygen) via NC (nasal cannula) at 2L/min (2 liters per minute). HOB (head of bed) remains elevated. AM nurse arrived on the unit early and went in the room with writer to assess as well; she took over resident's care at this time - following up with (physician). Unit manager was also made aware/assess site. Review of subsequent nursing notes on [DATE] for R15 revealed a wound culture was taken of the right leg surgical wound. Doppler results were negative for blood clot and the resident was started on an antibiotic to rule out infection. Review of the [DATE] Situation, Background, Assessment and Recommendation Communication Form (SBAR) and Progress Note for R15 revealed documented at 4:23 p.m. revealed, at 11:15 a.m. R15 had to be lowered to the floor today while being transferred from bed to her wheelchair. The operation site on her right hip was bleeding. She also has a skin tear on her right ankle that was bleeding. Vitals are within normal limits. Resident's (son) and (physician) notified. A stat X-ray of right hip and femur has been ordered. Skin tear on right ankle has been cleaned with normal saline and covered with a bandage. Operation site on right hip has been cleaned with normal saline and covered with a bandage. The form did not include evidence of a thorough investigation into the root cause of lowering her to the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what staff thought happened, whether staff education would be beneficial or what interventions could be put in place to prevent recurrence. Review of nursing notes on [DATE] for R15, revealed the hip wound was monitored, there was no drainage, an X-ray revealed intact hip arthroplasty no change and no new orders. Review of the [DATE] X-ray results for R15 revealed, anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Conclusion: Intact bilateral hip prostheses. Review of the nursing notes on [DATE] for R15 revealed the resident was sent to the hospital and returned without new orders. Review of the nursing notes for R15 between [DATE] and [DATE], revealed R15 continued on antibiotic for right thigh surgical site infection, diagnosed with [REDACTED]. ([DATE] CXR right lower lobe infiltrate) Review of the [DATE] nursing note for R15 documented at 2:49 p.m. revealed, resident alert, returned from (orthopedics appointment) during this some discomfort noted - PRN (as needed) medication administered during this time. Resident sutures removed and TX (treatment) to lower right leg is to be d/c (discontinued), also noted resident is to have :no weight bearing until follow-up visit on (MONTH) 4, (YEAR). Review of the [DATE] SBAR Communication Form and Progress Note for R15 documented at 4:39 a.m. revealed, R15 was yelling and found on the floor, resident was re-directed to call for assistance and continuous monitoring; said she wanted to get out of the bed, was very anxious yelling (did) not pay attention at all when (being) directed with what to do, needs more constant monitoring and redirection at all times. Frequent family visits to keep resident accompany. The form did not include evidence of a thorough investigation into the root cause of how she ended up on the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what the resident was doing last time staff checked on her, what staff thought happened, whether staff education would be beneficial or what interventions were put in place to prevent recurrence. Review of the [DATE] nursing note for R15 documented at 8:41 a.m. revealed, R15 was very anxious, yelling and was found on the floor at 4:30 am by the charged nurse and resident care specialist. Assessment was done and vital signs taken. Assisted back to bed with hoyer lift. Denies any pain distress discomfort. Redirected to call for assistance and safety intervention for floor mat to be on the floor while resident in the bed. Will continue with plan of care. Review of the [DATE] X-ray results for R15 revealed, there is prosthetic right femoral head in proper alignment with respect to the acetabulum. There is no fracture or acute dislocation. The prosthesis is properly situated without any loosening. Pubic rami are normal. Conclusion: Intact right hip arthroplasty, unchanged from [DATE]. Review of subsequent nursing notes for R15 on [DATE] revealed the resident was confused, calling out for help throughout the night, received an order for [REDACTED]. Review of the [DATE] nursing note for R15 documented at 12:48 a.m., revealed the physician was called about the resident's complaints of pain and ordered an X-ray of the right hip. Review of the [DATE] nursing note for R15 documented at 11:46 a.m. revealed, R15 continues to c/o pain to her left hip per therapy. This author asked resident if she was having pain now. Resident stated, 'No not when I am sitting down.' This author notified MD and new order was received for an AP and lat (X-ray) of the left hip. Resident continues to yell out when someone goes into her room she is quiet asking them to keep her company. Will continue to monitor. Review of the [DATE] X-ray results for R15 revealed, Hip unilateral w (with) pelvis ,[DATE] V (view) left; comparison: (MONTH) 16/ (YEAR); Findings: Anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Review of the [DATE] nursing note for R15 documented at 2:57 p.m. revealed, report of the entire xray was read to (physician). No new orders recd (received) for the UA results which was called to the (physician). This author called the residents granddaughter (name) who said my dad is on a plane and he will not be back for a week. Labs were drawn and she understands that the results will be recd on tomorrow. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 7:48 a.m. revealed, R15 is alert, yelling please get me out of bed. Nurse noted resident has legs on the side of the bed, with linen covers off of her. Nurse place resident legs into bed. Nurse returned to find resident had removed her legs to the rt. side of bed. Floor mat is in place, bed is in lowest position for safety precautions. Nurse will continue to monitor. Review of the [DATE] nursing note for R15 documented at 8:24 a.m. revealed, noted left lower leg black bruised. Edema in both lower legs. Resident is very agitated vitals not stable, in bed sleeping legs elevated. Review of the [DATE] nursing note for R15 documented at 8:27 a.m. revealed, upon assessment noted dark purple discoloration noted to left lower extremity. 3+edema noted to bilateral lower extremity. Denies pain/discomfort. Foot of the bed elevated. Called the physician made aware. New order noted venous Doppler done to bilateral lower extremities. Review of the [DATE] nursing note for R15 documented at 6:50 a.m. revealed, called the X-ray provider to receive copy of result from venous Doppler. Awaiting results. Resident rested well throughout the shift. Received results. Passing along to day shift nurse to report results to physician. Review of the [DATE] nursing note for R15 documented at 8:19 a.m. revealed, gave report to (physician) about resident's results from venous Doppler lower bilateral extremities. Made aware that results stated indeterminate for deep vein thrombosis and it recommends for test to be repeated. New order to have test repeated and begin resident on (blood thinners). Review of the [DATE] nursing note for R15 documented at 11:45 a.m. revealed, report was called to the hospital at 11 am and resident left the facility via ambulance accompanied by two emergency medical technicians (EMTs). Review of the [DATE] nursing note for R15 documented at 12:03 p.m. revealed, R15 was admitted to the hospital today. Review of the [DATE] nursing note for R15 documented at 3:55 p.m. revealed, abnormal lab work returned and call placed to physician informed of possible Deep Vein Thrombosis (DVT) per Doppler results study. New order noted to send out to hospital emergency room for evaluation and repeat Doppler study related to left (L) lower extremity. Review of the hospital record's for R15 dated [DATE] documented, history and physical revealed Chief Complaint: leg pain. History of present illness: This is a [AGE] year-old with a history of congestive heart failure, hip fracture, which was apparently atraumatic. The patient had an ORIF performed on [DATE]. The patient had a hospitalization complicated by a urinary tract infection. The patient has a questionable history of diastolic heart failure and was on lasix and the patient was discharged to a rehab facility. At the rehab facility, the patient was sub acutely complaining of pain around the prosthesis. The patient's complaints got worse. The patient had no [DIAGNOSES REDACTED], wound drainage, etc. No shortness of breath, no chest pain, no fever, no chills. She was brought back to the emergency room and a periprosthetic fracture was noted, Past surgical history: ORIF in (MONTH) 2010, right hip fracture and repair in 2008 is status [REDACTED]. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. They have decided on palliative care on left lower extremity (LLE), pain with motion at L hip, right lower extremity (RLE) , incision healed well. RLE; R15 is non-ambulatory at baseline. Proceed (with) palliative care as decided by family. NWB (non-weight bearing) LLE and NWB RLE; (MONTH) work on transfers and pain control. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. NWB status. Palliative care managing pain. Review of the [DATE] nursing note for R15 documented at 8:22 p.m. revealed, return from hospital at this time, Resident was admitted to hospice at this time see new orders in place. Review of nursing notes between [DATE] and [DATE] for R15 revealed the resident was in a lot of pain, medicated for pain with routine and PRN meds, and frequently called out in pain. Review of the [DATE] nursing notes for R15 documented at 9:58 a.m. revealed, Placed a call to physician to verify medication made physician aware that the resident is on scheduled medication, educated physician the resident is yelling help, help, and she is in pain. Family member had concerns resident is in pain was not being controlled. Resident has no labored breathing. Resident is in bed in lowest position with mats in place. Will continue to monitor resident. Review of the [DATE] nursing note for R15 documented at 4:58 a.m. revealed, Resident was yelling throughout the night. Upon entering resident's room she stated I don't know what's wrong with me. Stated she was in pain, gave PRN methadone, also gave Ativan 1 mg due to anxiety. Bed in lowest position with mats in place. Resident is on 3L of O2 via nasal cannula. No shortness of breath noted. Respirations even and unlabored. Will continue to monitor resident. An anonymous interested party (AIP) was interviewed on [DATE] at 9:00 a.m., by the State Survey Agency complaint intake staff. The AIP said the facility was responsible for R15's recent hip fracture, due to gross negligence and the resident was subsequently put on hospice services. Review of the [DATE] nursing note for R15 documented at 11:36 p.m. revealed, Resident and family members invited to 72 hr (hour) care conference meeting today, discussed in details hospice procedure and services that will be provided for resident. Also discussed pain and agitation medication that's will be provided by hospice. Social Worker requested that family provide personal sitter for resident for so many hours throughout the day according to their preference, (family member) stated that it's very hard to see his mother decline and he's unable to do more for her, he latter stated that he will sit down with his family and discuss issues and concerns that was discussed in this meeting. Review of the [DATE] nursing note for R15 documented at 9:58 a.m. revealed, Resident is in coma state at this time, hospice nurse at bedside, son at bedside. Review of the [DATE] nursing note for R15 documented at 7:52 p.m. revealed, On arrival today to 2nd shift, resident was unresponsive, (about 5:45 p.m.) Resident began moving around and yelling as usual. She received her afternoon meds as requested per (family). For now her vitals look ok and she is alert and stable. Review of the [DATE] nursing note documented at 2:52 p.m. revealed, Resident has eyes open-glossy and fixated, respirations labored. Resident has family at bedside during this time. Review of the [DATE] nursing note for R15 documented at 11:32 p.m. revealed, Resident alert new orders in place. Resident condition changed hospice notified. resident pain meds administered tolerated well, family members at bedside will continue to monitor. Review of the [DATE] nursing note for R15 documented at 6:20 a.m. revealed, Resident was alert and speaking out hello. Family member at bedside. Review of the [DATE] nursing note for R15 documented at 11:44 a.m. revealed, Resident is on Hospice. Moaning and body movements noted . Resident is resting peacefully . Family at bedside. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 4:24 p.m. revealed, Resident awake and alert at intervals. Total care provided per nursing and hospice care in all aspects of daily living. Resident turned and repositioned for comfort q (every) 2 hrs and as requested. Pain medication administered as scheduled, to include break thru pain relief. Medication effective. Review of the [DATE] nursing note for R15 documented at 2:45 p.m. revealed, resident in comatose state . labored breathing upon assessment wet. (R15) has family member at bedside at this time. Review of the [DATE] nursing note for R15 documented at 5:47 p.m. revealed, no pulse no respiration no blood pressure. (Hospice) notified to come to facility to pronounce patient at this time. Hospice nurse arrived at 6:00 pm. to assess patient and to do pronouncing of patient family at bedside. The Corporate Clinical Auditor (CCA), who was also a registered nurse, was interviewed on [DATE] at approximately 11:30 a.m. She said the SBARs are investigations into the falls and there were no other investigations. She said the process was to discuss the previous day's falls at the daily clinical meeting and weekly at the At Risk meeting. The CCA said, generally, they discussed where the resident was, what happened, was there any injury, what can we do, have interventions worked, some will fall, prevent injuries. She said she was not there when R15's falls were discussed. When asked for evidence of what was discussed at the daily clinical meetings and weekly At Risk meetings regarding R15, the CCA said she could provide fall protocols, but did not have documented evidence of the meetings. Review of the August, 2012 Fall Management, Overview, Practice Guidelines revealed: Each resident is assisted in attaining maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Each facility will take a proactive approach for new residents admitted and will consider all residents to be at risk for falls until reviewed by the IDT. A fall Care Plan will be initiated upon admission for each resident. When a fall occurs, assess resident for injury. The Licensed Nurse will complete: Incident/ Accident Report (Briggs); 24 Hour Report (Briggs); and Initiate the Interdisciplinary Post Fall Review. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form . The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post-Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. The nurse will communicate the resident fall to the IDT via the 24 Hour Report (Briggs). The IDT will review all resident falls within ,[DATE] hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. OPTIONAL: Fall information may be added to the Electronic Care Management Board (ECMB) if so desired for tracking purposes. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS (certified nurse aide) Assignment Sheets/ Care Kardex are updated as appropriate. The IDT will complete the Interdisciplinary Post Fall Review (see forms tab). The In-House Communicator form (Briggs) should be used to make referrals to appropriate IDT members. IMPORTANT: A Change of Condition form must be completed, if indicated by resident assessment. The Director of Nursing or designee will document falls on the Incident/Accident Report QA&A (Quality Assurance & Assessment) Log and the Individual Resident Fall QA&A Log (see forms tab) as they occur and submit reports to risk management system as indicated. Risk management system reports may be used, if desired, to complete tracking/trending reports for QAPI (Quality Assurance Performance Improvement). The NHA was interviewed on [DATE] at approximately 4:00 p.m. He said the facility was already cited deficient practice for R15 on a previous complaint ending on [DATE]. 2. R28 was observed on [DATE] at 1:35 p.m. with the wound care nurse. The wound care nurse said R28 was admitted with both of his pressure ulcers, a stage 4 on his sacrum and a stage 2 on his right posterior thigh. The wound care nurse confirmed there was an 8 outlet yellow surge protector power strip taped to the floor between R28 and his roommate - plugged in to the power strip were R28's suction machine, R28's humidifier and the roommate's oxygen concentrator. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or R29, who were roommates, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to install a power strip in R28's room. The NHA said both R28 and R29 had more medical equipment than they had outlets in the room. The NHA stated that a decision was made to unplug the bed of R28 for a few days. The NHA stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The NHA and the Maintenance Director were interviewed on [DATE] at approximately 10:30 a.m. The NHA confirmed R28's family member (F1) talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed. The NHA also confirmed a few days went by before he became aware the power strip was not installed. The NHA said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place. | 2019-11-01 |
| 4497 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 323 | G | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were provided with interventions and supervision to prevent repeat falls for 1 of 12 sampled residents (R4). Resident (R4) sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization . Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 3/7/16 admission Minimum Data Set (MDS) assessment revealed the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Closed record review for (R4) on 8/31/16 at 9:40 a.m. revealed upon admission the resident was assessed for falls and a care plan was generated on 3/9/16. Review of the care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 who is a bilateral above the knee amputee was heard in her room screaming for help. A Certified Nurse Aide (CNA) went to R4's room and alerted the nurse to come and assist because the resident had fallen and help was needed to get the resident off the floor. Review of a form in the closed record labeled Nursing assessment dated [DATE] revealed the resident sustained [REDACTED]. The resident was seen by the facility's physician and an X-ray was obtained with negative finding. An updated plan of care dated 3/23/16 revealed the resident fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident's wheelchair for proper functionality and keep items within reach. There was no documented evidence of determining the root cause of the fall or implementing other interventions to prevent future falls. Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident's wheelchair revealed he had a Maintenance Log Book kept at each nurses' station. He said the Maintenance Book was checked frequently. The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further reported most staff would simply tell him what needed to be fixed while passing in the hallways or elevator. When asked if he ever assessed a wheelchair on behalf of R4, he reported he remembered the resident when she was in the facility but did not recall a request to assess the wheelchair. He further stated he and the therapy department worked together on wheelchairs and he would double check the Maintenance Log Book. On 9/1/16 at 12:40 p.m. the Maintenance Director reported he was never informed of a request to look at R4's wheelchair and never assessed her wheelchair for proper functioning. During an interview with the SDC on 9/1/16 at 10:30 a.m. she reported, according to the resident's electronic record, the SBAR (Situation, Background, Assessment and Recommendation) note dated 4/5/16 timed 8:00 a.m. revealed the resident again fell from her wheelchair and sustained an injury. The resident was found in her room lying on the floor on her left side. Resident stated she finished brushing her teeth by the bathroom sink and was wheeling herself back to her table when she leaned forward too far and fell . Nurse's notes revealed the resident's injuries consisted of blood coming from her nose and a laceration noted on the bridge of her nose. A hematoma was noted above and around the resident's left eye. Two staff assisted the resident from the floor into the bed and the bleeding stopped. The Nurse Practitioner was in the facility, assessed the resident and instructed staff to send the resident to the hospital for evaluation and treatment. A detailed review of the hospital notes revealed the resident presented to the hospital per stretcher after her fall in the facility. According to the Emergency Physician notes dated 4/5/16, the resident had facial injury and bruising, left facial swelling and nose bleed. Results of Computed Tomography (CT scan) revealed mildly displaced fracture of the left orbital and medial wall. HemoSinus due to trauma, Left periorbital and frontal soft scalp tissue hematoma, Irregularity of the nasal bone and questionable age indeterminate nasal bone fractures. R4's pain was documented in the ER as moderate. The ER physician described the findings as suspicious and documented his concern for the resident safety. The resident did not return to the Nursing Center according to the closed record. She was discharged home from the ER with family and home health on 4/5/16. | 2019-09-01 |
| 4496 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 282 | G | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were provided with interventions as outlined on the care plan for 1 of 12 sampled residents (R4). Resident (R) 4 sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization (Cross Reference F323). Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The 3/7/16 admission Minimum Data Set (MDS) assessment indicated the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Review of the 3/9/16 care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 was found on the floor. The care plan was updated on 3/23/16, indicating that the resident's fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident's wheelchair for proper functionality and to keep items within reach. Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident's wheelchair revealed he had a Maintenance Log Book kept at each nurses' station. He said the Maintenance Book was checked frequently. The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further reported most staff would simply tell him what needed to be fixed while passing in the hallways or elevator. When asked if he ever assessed a wheelchair on behalf of R4, he reported he remembered the resident when she was in the facility but did not recall a request to assess the wheelchair. He further stated he and the therapy department worked together on wheelchairs and he would double check the Maintenance Log Book. On 9/1/16 at 12:40 p.m. the Maintenance Director reported he was never informed of a request to look at R4's wheelchair and never assessed her wheelchair for proper functioning; the resident's care plan was not implemented. | 2019-09-01 |
| 2996 | EAGLE HEALTH & REHABILITATION | 115618 | 405 S COLLEGE ST | STATESBORO | GA | 30458 | 2017-12-18 | 842 | D | 1 | 0 | OZA311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that care which followed the physician's orders for one resident, Resident (R)#1, of five sampled residents related to care and maintenance of a peripherally inserted central catheter (PICC) and maintenance of a gastrostomy tube ([DEVICE]) insertion site was documented in the resident's record, as preformed. Findings include: Record review revealed that the resident was admitted to the facility on (MONTH) 16, (YEAR) then transferred on (MONTH) 27, (YEAR) to an acute care hospital at the request of the family. Record review of R#1's admitting Physician's Orders dated (MONTH) 16, (YEAR), revealed orders to change the PICC line dressing every seven days and as necessary (PRN) when soiled, and orders to change the PICC line catheter cap every seven days, with blood draws, and PRN. Review of additional Telephone Orders, from the physician, were received and documented that same day in the Physician's Orders, without a time documented, to require observation of resident's sutures to the [DEVICE] site daily for signs and symptoms of infections, and to remove sutures from [DEVICE] site on 11/24/2017. Review of the R#1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation confirming that the PICC line dressing was checked or changed on 11/24/2017 or that the PICC line cap was changed on 11/24/2017, as indicated in the MAR. Continuing review of the MAR revealed that the [DEVICE] site was not recorded as checked on 11/23/2017 through 11/27/2017 and the sutures for R#1's [DEVICE] site were not recorded as having been removed on 11/24/2017. Review of R#1's Interdisciplinary Progress Notes revealed there was no documentation to confirm that the PICC line dressing was checked or changed on 11/24/2017, the PICC line cap was changed on 11/24/2017, nor the [DEVICE] site was checked for five days and there was not evidence that the [DEVICE] sutures were removed on 11/24/17. Interview with the Wound Care Nurse, Licensed Practical Nurse (LPN) GG on 12/18/2017 at 12:30 p.m. revealed that the orders should have been followed and agreed there was no evidence that this was done. LPN GG stated that she was on vacation during this time frame and other staff were providing wound care for the resident. During interview with the DON on 12/18/2017 at 4:35 p.m. to review R#1's Physician's Orders, the MAR and TAR, all dated 11/16/17 through 11/27/17, she confirmed that Physician Orders had been written for the PICC line dressing change on 11/24/2017 and the PICC line cap change on 11/24/2017, and the orders were transferred to the MAR but were not recorded as having been performed. Continuing review of Physician's Orders and the MAR, dated (MONTH) 16, (YEAR) revealed that the [DEVICE] site was not recorded as checked on 11/23/2017 through 11/27/2017 and the sutures for R#1's [DEVICE] site were not recorded as having been removed on 11/24/2017. The DON placed a phone call to LPN LL who provided care for the resident on 11/24/2017 who revealed that she was sure she did everything the resident needed that day but forgot to document it. | 2020-09-01 |
| 15 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 656 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. During interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes from 5/10/19 confirmed RB reporting the use of silver dressings to her lower extremity wounds. Cross refer to F684 | 2020-09-01 |
| 1160 | SOUTHLAND HEALTHCARE AND REHAB CENTER | 115376 | 606 SIMMONS ST | DUBLIN | GA | 31040 | 2019-12-10 | 569 | D | 1 | 0 | TW0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that the resident trust account balance remained under the $2000 limit to maintain eligibility for Medicaid services for one resident (#8), from a total sample of 12 residents. Findings include: The facility had a Resident Trust Fund policy. The policy documented that fund balances for Medicaid recipients should be monitored monthly by the Resident Trust Custodian to ensure that state maximum balances are not exceeded. Resident (R) #8 was admitted to the facility on [DATE]. A resident trust account was opened on 6/18/19. A review of the Authorization and Agreement to Handle Resident Funds form revealed that the resident had enrolled in a non-transferring resident fund account and opted for direct deposit of social security and supplemental security income. A review of the account activity for R#8 revealed that the account balance exceeded the $2000 limit from 10/1/19 through 12/9/19. However, there was no evidence that the facility addressed the balance of excess funds, that began in October, until 12/9/19. During interviews on 12/9/19 at 3:40 p.m. and 4:20 p.m., the Business Office Manager stated that she had been in contact with the social security office because R#8 continued to receive her full benefits check, and she did not know if the social security office was aware the resident was in a nursing home. A review of a facsimile cover sheet revealed that contact with the social security office did not occur until 12/9/19. | 2020-09-01 |
| 16 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 684 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED]. | 2020-09-01 |
| 4691 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 282 | G | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to follow the care plan for 1 of 9 sampled residents (R4) related to bowel management, which resulted in R4 having a stool impaction. After R4's hospitalization , the facility failed to monitor R4's bowel movements (BMs) and initiate bowel medications timely per the care plan, which increased the likelihood for further impaction, and causing actual harm. Findings include: The Admission Record indicated R4's [DIAGNOSES REDACTED]. The 2/4/16 plan of care related to bowel incontinence with a risk of constipation, included: Document episodes of incontinence each shift; observe for bowel movement (BM) each shift; report if no BM for 2-3 days, and administer medications as ordered. The Quarterly Change in Status Minimum Data Set (MDS), with an assessment reference date of 4/14/16, indicated R4 had severely impaired cognition, was dependent on staff for toilet use, and was always incontinent of bowel function. The 4/8/16 BM Report indicated R4 had a small, soft BM. The BM Report dated 4/9/16 to 4/21/16 (13 days) indicated R4 did not have any BMs. The 4/22/16 BM Report indicated R4 had a small BM. During an interview with Licensed Practical Nurse (LPN) 3 on 8/18/16 at 10:45 a.m., she said the Nurse Aides (NAs) were to report to the nurses when a resident did not have a BM for 2 to 3 days. LPN3 said between 4/8/16 and 4/22/16, the NAs did not report that R4 had any bowel issues. The 4/22/16 Situation, Background, Assessment, Recommendation (SBAR) Communication Form indicated R4 had an elevated heart rate of 102, and elevated temperature of 102 degrees Fahrenheit, an elevated blood sugar of 170, and a decreased oxygen saturation level of 89 %. The SBAR Communication Form indicated R4 was not responding as usual and refused to eat, drink, or take his medications. During an interview with Registered Nurse (RN) 14 on 8/19/16 at 11:10 a.m., RN14 said on 4/22/16, R4 had a decline in his medical status and the staff transferred R4 to the Emergency Department for an evaluation. The 4/29/16 Hospital Physician Discharge Summary indicated R4 complained of abdominal pain and had abdominal tenderness to palpation, likely due to stool impaction. The Physician Discharge Summary indicated a CT (computerized tomography) scan of the abdomen revealed marked distention of the rectum with a large fecal ball extending into the sigmoid colon with upstream dilatation of multiple loops of colon which were filled with air and stool. The 4/30/16 Nurse's Note indicated the staff admitted R4 back to the facility and his [DIAGNOSES REDACTED]. During an interview with the Director of Health Services (DHS) on 8/19/16 at 9:30 a.m., the DHS said although there was no facility Bowel Policy, the nurses were to follow the physician's orders [REDACTED]. The DHS said the NAs did not notify the nurses that R4 did not have a BM for greater than 3 days. The DHS said the nurses did not administer bowel medication to R4 per the Physician Order. The DHS said the staff did not follow R4's plan of care related to bowel management. The BM Report dated 5/29/16 to 6/4/16 (7 days), indicated R4 did not have any BMs. The day shift 6/4/16 Nurse's Note indicated the NA reported R4 did not have a BM for 3 days and a laxative was given as ordered for constipation. The DHS said the NAs did not notify the nurse of R4's lack of BMs; the nurse did not give R4 timely bowel medication, and the staff did not follow R4's plan of care related to bowel management. The BM Report dated 6/10/16, 6/12/16, 6/16/16, 6/17/16, and 6/18/16 did not indicate R4 had any BMs. There was no documentation on the BM record dated 6/11/16, 6/13/16 to 6/15/16 to indicate if R4 had any BMs. During interviews with CNA13 on 8/18/16 at 3:00 p.m., CNA13 said some of the NAs did not have access to enter a resident's BMs in the computer and the nurses were to enter that information in the computer. During an interview with the Corporate Nurse on 8/18/16 at 2:00 p.m., she said there was inconsistent documentation regarding R4's bowel history. The Corporate Nurse said the NAs and/or the nurses did not always document whether R4 had a BM, therefore the nurses were not able to determine if R4 needed bowel medication due to the staff not following R4's plan of care. Refer to F309 The facility failed to ensure that R4 received the appropriate care and services to maintain the highest practicable well-being. The facility failed to assess and follow R4's plan of care related to bowel management, which resulted in R4 having a stool impaction. | 2019-08-01 |
| 3231 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-11-27 | 580 | D | 1 | 0 | SH9Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the responsible party, in a timely manner, of the development of a pressure ulcer for one resident (A) from a total sample of six residents. Findings include: Resident (R) A had a new physician's orders [REDACTED]. During an interview on 11/27/18 at 2:08 p.m. Licensed Practical Nurse (LPN) AA stated that on 10/5/18 the order was written for a pressure ulcer. The pressure ulcer was a closed, dark, Deep Tissue Injury (DTI). However, there was no evidence in the clinical record that the resident's responsible party was notified of the pressure ulcer or treatment ordered on [DATE]. On 10/18/18 the consultant wound care physician evaluated R [NAME] A nurse note entry documented an unsuccessful attempt to notify the resident's responsible party and second contact person of the wound care physician's visit and wound debridement that occurred on 10/18/18. However, after the initial documented attempt on 10/18/18, there was no further evidence in the clinical record that further attempts were made to notify R A responsible party of the pressure ulcer to the sacrum until 11/1/18. During an interview on 11/27/18 at 2:43 p.m., R A's responsible party confirmed that she was not notified of when the pressure ulcer was first identified. | 2020-09-01 |
| 2980 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 808 | D | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to obtain a therapeutic diet consultation, as ordered by the physician, for one of three residents (R#5) reviewed for diets. Findings include: Resident (R) #5 had [DIAGNOSES REDACTED]. There were care plans in place for the potential for alteration in nutrition and a desire to lose weight with an intervention for a Registered Dietician (RD) consultation and/or evaluation as needed. A review of the Yearly Weight Record Form for 2019 revealed that R#5 had lost 11 pounds, as care planned, since 2/15/19. A review of the clinical record revealed R#5 had been receiving a no added salt (NAS), liberalized diabetic (LDD), regular consistency diet since 2/18/19. On 5/2/19 R#5 received a cortisone injection to the left knee. A review of the physician's note from 5/2/19 revealed a [DIAGNOSES REDACTED]. Following the cortisone injection, an order was written on 5/2/19 to obtain a dietician consultation with the resident to discuss a low carbohydrate, weight reduction diet for DJD of the left knee and [MEDICAL CONDITION]. However, there was not any evidence in the clinical record that the dietician consultation was obtained as ordered until after surveyor inquiry on 6/25/19. During an interview on 6/25/19 at 2:00 p.m., the Assistant Director of Health Services (ADHS) confirmed that the physician's orders [REDACTED]. On 6/25/19 the RD was notified of the order via the Registered Dietician E-Fax Recommendation Form. The RD responded on 6/25/19 with a recommendation to discontinue the NAS, LDD, regular consistency diet and start a NAS, no concentrated sweets (NCS), regular consistency diet, adding fruit only for desserts. During an interview on 7/3/19 at 10:30 a.m. the Director of Health Services (DHS) stated that she would have expected nursing staff to have acted on the 5/2/19 order for the dietician consultation prior to surveyor inquiry on 6/25/19. | 2020-09-01 |
| 3232 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-11-27 | 625 | E | 1 | 0 | SH9Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide bed hold information at the time of transfer to the hospital or within 24 hours for three residents (#2, #5, and #6) from a total sample of six residents. Findings include: The facility's Bed Hold policy documented that the resident and a family member or legal representative shall be given notice of the bed hold options at the time of hospitalization or therapeutic leave. However, there was no evidence that the facility provided bed hold information at the time of hospitalization or within 24 hours for residents #2, #5 and #6. 1. Resident (R) #2 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission on 3/3/17, a review of the clinical record revealed no evidence that the resident and responsible party were provided with information on bed hold also at the time of transfer or within 24 hours for the 10/18/18 hospitalization . 2. R#5 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission on 10/5/17, a review of the clinical record revealed no evidence that the resident and responsible party were provided with information on bed hold also at the time of transfer or within 24 hours for the 10/30/18 hospitalization . 3. R#6 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission on 10/12/18, a review of the clinical record revealed no evidence that the resident and responsible party were provided with information on bed hold also at the time of transfer or within 24 hours for the 11/2/18 hospitalization . During an interview on 11/27/18 at 10:00 a.m., the Social Service Director stated that bed hold information had not been provided at the time of hospitalization for R#2, R#5 and R#6. | 2020-09-01 |
| 1028 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2018-12-17 | 580 | D | 1 | 0 | S35E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record reviews the facility failed to notify the Physician/Nurse Practitioner (NP) of a transfer to the hospital for one resident (C) of three sampled residents. Findigs include: Review of the undated face sheet in the Electronic Medical Record (EMR) for R C revealed the resident was admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. Contnued review of the undated [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], section C, revealed R C to have a Brief Interview for Mental Status (BIMS) score of three out of 15, signifying severely impaired cognition. Review of section G of the MDS revealed the resident required either extensive assistance or was totally dependent on caregivers for all of her Activities of Daily Living (ADLs). Review of a progress note, dated 11/3/18 at 7:10 p.m. revealed the resident's family came in to visit and noted the resident was sleeping. Further review revealed that the family member asked the staff nurse if the resident had been sedated and the nurse stated the resident had not been sedated. Further review revealed that the resident's family member then called the 911 without discussing the call with the nurse and that the resident was transferred to a nearby Emergency Department (ED). Review of a progress note, dated 11/3/18 at 7:58 p.m. revealed a late entry describing an earlier, but unstated time, revealed the staff Licensed Practicial Nurse (LPN) BB wrote that R C was sleeping during rounds but easily aroused. Further review revealed that the resident opened her eyes when her name was called when the paramedics arrived. A telephone interview on 11/29/18 at 2:15 p.m. with (LPN) BB revealed that she was the resident's nurse the evening that the family member called 911 and took the resident to the hospital. LPN BB stated after she came on duty she visited and assessed R C. LPN BB further revealed that she had no concerns about R C at that time. She stated R C was asleep but woke up and spoke to her when she came in the room. LPN BB further confirmed that the resident's family member came in a little later and asked her if R C had been sedated and she told the daughter no. She stated the next thing she knew, the paramedics had arrived and they were putting the resident on a stretcher. LPN BB further revealed that the resident's eyes were open, and that the resident followed all the commotion in the room, but she did not remember if the resident said anything. A telephone interview on 12/5/18 at 4:00 p.m. with the Medical Director revealed that she did recalled R C and was the resident's physician. She further revealed that she did not recall being notified that the resident went to the hospital and that it is expected for nursing to notify her or the NP if any resident went to the hospital. She stated it would be unacceptable to not notify her. An interview on 12/5/18 at 4:45 p.m. with the Director of Nursing (DON) revealed that she expected, as a matter of policy, that report of a resident's condition be given by a nurse, any time, a resident was sent to another facility for any reason. She stated that paperwork should be done and handed to the receiving facility or transport personnel. She stated if a transfer or discharge was emergent, there would not be time to prepare paperwork, but a verbal report should be given and anything else was unacceptable. She also revealed that any time a resident was sent to the hospital that the physician or the NP should be notified. She stated the facility did not have written policy on these matters, per se, but any nurse would know, as a matter of professional standards, to give a proper report and to notify the physician or NP about any transfer or change of condition. A telephone interview on 12/17/18 at 2:48 p.m. with NP EE who works for the Medical Director revealed that he knew R C well. He stated he was not informed of the resident being taken to the hospital until he heard about it the following Monday which was two days later. He stated he, or the on-call NP or the physician should have been notified of any change of condition or transfer to the hospital for any resident. He stated not reporting to him or the doctor would be unacceptable. | 2020-09-01 |
| 4436 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 281 | J | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of resident records, the Georgia Practical Nurses Practice Act professional standards published in the Lippincott Procedures for Safe Medication Administration Practice, General, and the facility policy titled, Medication Administration General Guidelines, the facility failed to ensure that the services provided to 4 of 52 sampled residents (R7, R5, R25, and R34) met professional standards for medication administration. Specifically: Resident (R) 7 was given [MEDICATION NAME] (laxative medication) without a physician order and the [MEDICATION NAME] was mixed with Pine-Sol cleaning solution, without checking the label of the product. The hazardous solution was administered to R7. After staff administered the Pine-Sol to the resident and the resident took a sip of the solution, she complained of burning in her throat and required transportation to the hospital emergency room for evaluation. The facility failed to administer medication to R5 prior to a surgical procedure, as ordered by the physician. The facility failed to administer an antibiotic medication, to R25, until 3 days after it was ordered for an infection. The facility administered three doses of [MEDICATION NAME] (opioid pain medication) to R34 after the medication was discontinued by the physician. The census was 229. The facility's failure to ensure that medications were administered based on physician order caused, or was likely to cause serious injury, harm, impairment, or death to a resident. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. On 9/28/16 at 5:30 p.m. the Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F224 and F226 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. An acceptable Allegation of Compliance (A[NAME]) was received on 10/3/16 and Healthcare Management Solutions (HCMS), LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed on 10/4/16. The deficient practice remained at a D (potential for more than minimal harm) while the facility developed and implemented the Plan of Correction (P[NAME]) and the facility's Quality Assurance (QA) monitored the effectiveness of the systemic changes. After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: 1. TITLE 43. PROFESSIONS AND BUSINESSES CHAPTER 26. NURSES ARTICLE 2. LICENSED PRACTICAL NURSES 43-26-30. Short title: This article shall be known and may be cited as the Georgia Practical Nurses Practice Act. HISTORY: Code 1981, 43-26-30, enacted by Ga. [MI] 1992, p. 2151, 1. 43-26-31. Purpose of article the purpose of this article is to protect, promote, and preserve the public health, safety, and welfare through regulation and control of practical nursing education and practice. This article ensures that any person [MEDICATION NAME] or offering to practice practical nursing or using the title Licensed Practical Nurse, as defined in this article, within the State of Georgia, shall be licensed as provided in this article . The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law . Such care shall relate to the maintenance of health and prevention of illness through acts authorized by the board, which shall include, but not be limited to, the following: (A) Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations; (B) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, home health care, or other such areas of practice; (C) Performing comfort and safety measures; (D) Administering treatments and medication; and (E) Participating in the management and supervision of unlicensed personnel in the delivery of patient care . The statutory materials reprinted or quoted verbatim on the following pages are taken from the Official Code of Georgia Annotated, Copyright 1984, 1988, 1991, 1994, 1999, 2002, 2005, 2006, 2007, 2009, 2010, 2011, 2012, 2013 by the State of Georgia, and are reprinted with the permission of the State of Georgia. All rights reserved: According to Lippincott Procedures for Safe Medication Administration Practice, General, dated 10/2/15, relative to Verifying the Medication Order: Follow a written or typed order or an order entered into a computer order-entry system because these types of orders are less likely to result in error or misunderstanding. Make sure that the prescriber's order contains a diagnosis, a condition, or an indication for the medication. Verify that other essential elements of the medication order are present, including the patient's name, age, and weight (preferably in kilograms);9 the date and time the order was written; the name of the drug to be administered; the dosage of the drug; the route by which the drug is to be administered; the frequency of administration of the drug; dose calculation requirements (when applicable); exact strength or concentration of the drug (when applicable); the quantity of the drug or duration of administration (when applicable); specific instructions for use (when applicable); and the signature of the person writing the information. The facility Medication Administration General Guidelines revealed that medications are administered in accordance with written orders of attending physicians, prior to administration the medication and dosage schedule on the Medication Administration Record [REDACTED]. If a dose of medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the MAR for as needed medication documentation. 1. R7 was admitted to the facility most recently on 5/28/16. A review of physician orders dated from 5/28/16 through 9/6/16 revealed there was no order for R7 to receive [MEDICATION NAME]. (Refer to F281). A quarterly Minimum Data Set (MDS) assessment, dated 7/14/16, indicated R7 exhibited no cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. A review of the most recent plan of care to address medications, revealed that R7 should receive medications as ordered and be monitored for side effects. Review of a Supervisor Investigation Summary Form, dated 9/6/16, revealed R7 ingested a harmful substance (Cross Reference to F224) and received a medication ([MEDICATION NAME]) without a physician order. The form indicated that LPN302 administered the harmful substance and [MEDICATION NAME]. R7 was transferred to the Hospital for evaluation following the incident and returned the same day after signing out AMA (against medical advice). There was no change in her physician orders on return from the Hospital. A review of the physician orders for R7, dated from admission on 5/28/16 until 9/6/16 revealed there was no physician order for [REDACTED].>Medication Administration records (MAR), dated 9/6/16, revealed there was no order for [MEDICATION NAME] noted on the MAR. According to the Nurse's note, dated 9/6/16, at 11:06 a.m., the Nurse Practitioner (NP) was on the unit and R7 was assessed by the NP. Poison Control was notified and had no recommendations. R7 was transferred to the hospital for evaluation at 10:35 a.m. R7 was evaluated at the hospital and no issues related to the ingestion of the Pine-Sol were identified according to the emergency room Course notes, dated 9/6/16. emergency room Course notes documentation revealed that other unrelated medical issues were identified, the hospital wanted to have R7 remain for assessment and R7 signed out of the hospital AMA (against medical advice). An interview with the NP at 12:00 p.m. on 9/27/16 revealed that she was making rounds on the West Unit at the time of the incident on 9/6/16 and was asked to assess R7. She said R7 told her that she drank some of the [MEDICATION NAME] mixture which she reported LPN302 had mixed with Pine-Sol and that her (R7) throat was burning. The NP said R7 did not exhibit any acute symptoms related to the ingestion, but requested to go to the hospital. The NP said that R7 appeared very anxious. She said that facility staff notified the Poison Control Center. A physician order, dated 9/13/16, (7 days after R7 received the [MEDICATION NAME] on 9/6/16), revealed an order for [REDACTED]. During an interview with R7 at 4:45 p.m. on 9/26/16, she reported that a couple weeks prior a nurse mixed her [MEDICATION NAME] (medication for constipation) with Pine Sol disinfectant (purchased by R7's family and kept in R'7's closet) instead of green tea (also kept in R7's closet). R7 said that the nurse entered the room, opened the closet, and took out a bottle of liquid to mix the [MEDICATION NAME] with. R7 said she kept a bottle of Pine Sol in the closet and also kept her bottles of green tea in the closet. R7 said the nurse (could not recall exact name or date) took a bottle out of her closet, left the room and returned with the [MEDICATION NAME] mixture in a cup which she gave to R7 and R7 took a sip and swallowed the mixture. R7 said that as soon as she took a sip, her throat burned and she told the nurse, You mixed it with Pine Sol! During an interview with LPN302 at 11:38 a.m. on 9/27/16, LPN302 said that she grabbed what she thought was the green tea from R7's closet, took it to the medication cart and mixed it with the [MEDICATION NAME]. She said she took the cup back to the room and gave it to R7. She said R7 was rushing her and she did not follow the correct procedure for medication administration. LPN302 said she did not check the Medication Administration Record [REDACTED] Review of the personnel record for LPN302 revealed there was no documentation that would indicate previous medication errors or nurse practice issues. LPN302 had been employed by the facility since 4/19/04 as the MDS Assistant. On 9/6/16, LPN302 was assigned to the West Unit to pass medications and provide nursing care. LPN302 was terminated on 9/9/16. Review of the Skills Validation related to medication administration revealed LPN302 attended the training in (MONTH) (YEAR). Interview with the Director of Nursing (DON) at 9:45 a.m. on 9/27/16 revealed that there was no order for R7 to receive [MEDICATION NAME] on 9/6/16. The DON confirmed that LPN302 was allowed to finish her shift on 9/6/16, the incident was not reported to the SSA or the Board of Nursing in Georgia. 2. R34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) MAR, for R34, revealed that on 6/22/15 the physician ordered [MEDICATION NAME] (opioid pain medication) 5/325 milligrams, 1 tablet by mouth every 6 hours as needed for mild to moderate pain and 2 tablets by mouth every 6 hours as needed for moderate to severe pain. Review of the clinical record for R34 revealed that [MEDICATION NAME] was discontinued per a physician order on 1/12/16. Review of the Janaury (YEAR) MAR indicated [REDACTED]. Interview with LPN137 at 4:30 p.m. on 10/3/16, revealed that R34 had an order for [REDACTED]. LPN137 said she did not follow correct medication administration procedures relative to checking the physician order against the medication container three times prior to administration. LPN137 said she recalled giving the medication a second time, after it was discontinued. She said that she administered the dose on 1/12/16 prior to the time the order was written to discontinue the medication. There was no time noted on the physician order to discontinue it. She could not provide a reason for not following correct procedure. The MAR indicated [REDACTED]. Review of the Skills Validation related to medication administration revealed LPN137 attended the training in (MONTH) (YEAR). The Supervisor Investigation Summary Form dated 2/4/16 (when the issue was discovered) indicated disciplinary action was taken, (counseling), and the physician was notified. Interview with the DON at 9:00 a.m. on 10/3/16 revealed that the incident was reviewed, and LPN137 was written up and participated in med pass with pharmacy and facility staff, however, the incidents were not reported to the SSA or the Board of Nursing. The DON said that the correct procedure for medication administration was to verify the physician order on the MAR indicated [REDACTED]. 3. R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission assessment documentation, dated 4/20/16, revealed that R5 was alert and oriented to person, place, and time. The Admission physician orders for R5 revealed that she was scheduled for a surgical procedure on 4/25/16. A physician order, dated 4/20/16, revealed R5 was to have nothing by mouth after midnight on 4/24/16. R5's Preadmission Teaching and Testing form, dated 4/22/16, revealed that R5 should arrive at the surgery center on the morning of 4/25/16. The form indicated R5 was allowed to have the following medications, with a sip of water, prior to surgery on the morning of 4/25/16: [MEDICATION NAME] (pain medication) if needed, [MEDICATION NAME] (anti-anxiety medication) if needed, [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]), ProAir ([MEDICATION NAME][MEDICATION NAME]) if needed, [MEDICATION NAME] (Beta blocker), Dexilant (proton pump inhibitor to treat reflux), [MEDICATION NAME] (allergy medication), [MEDICATION NAME] ([MEDICAL CONDITION] hormone), [MEDICATION NAME] (narcotic pain medication), Liothyronine ([MEDICAL CONDITION] hormone), [MEDICATION NAME] (to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (SSRI to treat depression). Physician orders for R5, dated for (MONTH) (YEAR), revealed that R5 had physician orders to receive the following medications: [REDACTED]. Medication Administration Record [REDACTED]. However, there was no documented explanation for not administering the medications. The MAR for R5 dated 4/25/16 at 9:00 a.m. revealed that the signature area was blank for the following medications: [REDACTED] Interview with R5 at 1:20 p.m. on 9/28/16 revealed that she was given a list of medications that she was allowed to take on the morning of 4/25/16, prior to a planned surgical procedure. R5 said that she did not receive any of the medications. R5 could not recall the name of the nurse assigned to her that day. Review of the staff schedule for the West unit on 4/25/16 revealed that LPN147 was assigned to provide care for R5. An interview with LPN147 at 10:15 a.m. on 9/29/16 revealed that she worked the West unit where R5 resided. LPN147 said that she could not recall R5 or specifics related to the morning of 4/25/16 when R5 was scheduled for a surgical procedure, however, she confirmed that some of the medications on the MAR indicated [REDACTED]. She said that her practice was to circle medications that were not given. She said that R5 may have refused the morning medications, but she could not be sure. LPN147 said that if the medications on the MAR indicated [REDACTED]. She said she could not recall details because it was a long time ago. Interview with the Director of Nursing at 9:30 a.m. on 9/30/16 revealed that LPN147 did not follow the correct procedure/facility policy relative to medication administration, following physician orders for R5 and did not provide, according to the MAR, medications as ordered to R5 on 4/25/16. She said there was no further investigation of the incident. 4. R25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Laboratory results, dated 7/5/16, for a urinalysis indicated R25 had a urinary tract infection and an order was given for an antibiotic medication. Physician order for [REDACTED]. A Medication Error Report, dated 7/8/16, revealed that due to a transcription error, R25 did not receive the [MEDICATION NAME] until 7/8/16. The report indicated the Director of Nursing was notified of the error at 1:30 p.m. and the Physician was notified at 2:00 p.m. The report indicated the [MEDICATION NAME] was taken from the E-kit and started as soon as the error was found. The report indicated that the nurse, LPN109, who took the telephone order failed to write the order on the MAR for R25. Physician order for [REDACTED]. Attempts were made to reach LPN109, by telephone on 10/2/16 and 10/3/16. The surveyor was not able to leave a message for a call back as there was no answering machine. The Supervisor Investigation Form indicated that LPN109 was counseled on prompt initiation of medications. Interview with the DON at 10:00 a.m. on 10/3/16 revealed that there was no negative outcome to this incident and LPN109 was counseled relative to prompt initiation of medications. She said the nurse taking an order was responsible for adding it to the MAR. A group interview was conducted on 9/27/16 at 11:15 a.m. with residents whom the facility and/or survey team had identified as alert and oriented who could provide resident feedback on various concerns. During this interview, one resident stated, They try to give you the wrong one (medication) or at the wrong time. You have to tell the nurse 'That's wrong. The facility implemented the following actions to remove the Immediate Jeopardy: 1) All residents receiving medications have the potential to be affected. 2) Affected resident-chemical removed from resident room. QA team consisting of Activities, Housekeeping, Dietician, Social Service, Central supply, Medical records, and Human Resources will conduct rounds with census sheet as an audit tool weekly x 4 then monthly x 2 for chemicals in facility. Findings of audits will be discussed in QA meeting. 3) Facility wide chemical sweep conducted by Registered Nurse, Medical Records, Registered Dietician, Social Services, CNA, Assistant Executive Director, Human Resources, Central Supply, Business Office Manager, Assistant Director of Nursing, Director of Nursing, Dietary Manager, Executive Director on 9/6/16, 9/12/16, 9/19/16. Week of 9/26/16, Facility wide chemical sweeps continued by 3 R.N.s, 3Medical Records, CNA, 2 LPNs, 2 Activities, 2 Social Services, 2 Registered Dieticians, Central Supply, Business Office Manager, Dietary Manager. QA members consisting of Activities, Housekeeping, Dietician, Social Services, Central Supply, Medical Records, Human Resources and CNA, will continue to conduct rounds with the census sheet as audit tool weekly x 4 then monthly and give to the ED/AED for review and any deficient practice will be forwarded for review to the QA committee. 4) Affected resident has current order for [MEDICATION NAME] obtained on 9/13/16. 5) Nursing staff reinserviced on medication administration policy to include 6 rights of medication administration-right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. In-service began 9/27/16 by ADNS and RN/RT, Director of [MEDICAL CONDITION] Services. In-services will continue until licensed nurses have been reinserviced. On 9/28/16, in-services continue and the presenters are RN Case Mix Consultant, RN Assistant Director of Nursing, and RN/RT, Director of [MEDICAL CONDITION] Services. As of 9/29/16, in-services continue by LPN Pharmacy Consultant, and RN Case Mix Consultant. In-services will continue by LPN Pharmacy Consultant, Staff Development Coordinator, RN Unit Manager, RN Supervisor, LPN Supervisor, RN Assistant Director of Nursing, and RN/RT Director of [MEDICAL CONDITION] Unit. In-services will continue until 100% of licensed nurses have been reinserviced by 10/5/16.No licensed nurse will be allowed to work until in-service on medication administration has been completed. As of 10/3/16, 86% of licensed nurses have been reinserviced. 6) Medication administration skills competencies to include preparation, steps to perform medication administration of medication and completion of task related to the following competencies for medication administration: nebulizer, ear drop, eye drop, eye ointment, enteral tube,, nasal, insulin, nose drop, oral inhaler, oral powder inhaler, rectal suppository, sublingual, intramuscular injection and [MEDICATION NAME]. Competencies began on 9/27/16 by RN/RT, Director of [MEDICAL CONDITION] Unit, and RN Assistant Director of Nursing. Competencies continued on 9/28/16 by LPN Pharmacy Consultant. Competencies will continue by LPN Pharmacy Consultant, LPN Staff Development Coordinator, RN/RT Director of [MEDICAL CONDITION] Unit, RN Unit Manager, LPN Supervisor, RN Supervisor, RN Director of Nursing Services and RN Assistant Director of Nursing Services until complete. No licensed staff will be allowed to work prior to medication administration policy in-service to include medication administration skills competencies 7) Newly hired nurses will be in-service during orientation process on medication administration to include the 6 rights of medication administration-right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration by RN Director of Nursing or RN Assistant Director of Nursing, LPN Staff Development Coordinator, RN Supervisor, LPN Supervisor. 8) RN Director of Nursing, RN Assistant Director of Nursing, RN Supervisor, RN Unit Manager, LPN Supervisor, RN/RT Director of [MEDICAL CONDITION] Unit, LPN Staff Development Coordinator, will audit weekly x 4 then monthly with a total of 10 nurses for administering medications per medication administration policy including 6 rights of medication administration- right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. Medication administration observations will be given to ED/AED for review and any deficient practice will be forwarded for review by the QA committee. 9) Amendment made on 9/30/16 to admission paperwork/packet to include statement no cleaning chemicals i.e. Pine Sol, Clorox, Mr. Clean etc. not allowed to be kept in resident rooms. Additionally, this amendment will be presented to residents that are their own responsible party and provided to responsible partied for residents. 10) QA meeting was held on 9/29/16. Participants were: Executive Director, Assistant Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Director, Director of [MEDICAL CONDITION] Services, and Medical Director. 11) In-servicing related to chemicals found in resident rooms will continue quarterly for all staff. 12) Medication administration to include the 6 rights of medication administration- right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration will be in-service quarterly for licensed nurses. HCMS, on behalf of the State Survey agency, validated the implementation of the facility's Credible Allegation of Jeopardy removal as follows: 1) No action plan in this statement to verify. 2) The absence of chemicals in R7's room was verified during daily observations made during the complaint investigation of 9/26/16 through 10/4/16. The weekly audit from 10/3/16 was reviewed. Observations of 36 resident rooms (TCPU: 101, 102, 103, 104, 106, 107, 108, 109, 110, 111, 112, 113, and 114, and Main Building: 312, 308, 303, 221, 204, 56, 55, 54, 53, 52, 51, 38, 41, 40, 35, 33, 31, 30, 26, 22, 17, 11 and 4 ) on 10/4/16 verified no chemicals were present in resident rooms. 3) Documentation of the resident room sweeps for chemicals was reviewed. These sweeps occurred 9/6/16, 9/12/16, 9/19/16, 9/27/16 and 9/28/16. Documentation reviewed no chemicals were found in resident rooms. 4) A new physician order for [REDACTED]. 5. In-service records of 16 nurses (RN272, RN273, RN 277, RN94, LPN288, LPN283, LPN147, LPN137, LPN135, LPN133, LPN128, LPN120, LPN116, LPN110, LPN108, and LPN105,) passing medications on 10/4/16 revealed that all had received the in-service identified in the A[NAME]. During interviews conducted on 10/4/16 with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., RN 277 at 10:25 a.m., RN 94 at 8:40 a.m., LPN 288 at 10:15 a.m., LPN 147 at 8:25 a.m., LPN 283 at 11:05 a.m., LPN 147 at 8:25 a.m., LPN 137 at 8:40 a.m., LPN 135 at 8:40 a.m., LPN 133 at 8:32 a.m., LPN 128 at 10:09 a.m., LPN 120 at 9:25 a.m., LPN 116 at 8:26 a.m., LPN 110 at 9:30 a.m., LPN 108 at 8:27 a.m., and LPN 105 at 8:29 a.m., the 16 nurses interviewed on 10/4/16 verified their attendance at in-services on medication administration. 45 random nurse records were also reviewed for in-servicing on medication administration. All nurse records that were reviewed were found to contain evidence of the in-service described in the A[NAME]. 45 random nurse records were also reviewed for in-servicing on medication administration. All nurse records that were reviewed were found to contain evidence of the in-service described in the A[NAME]. 6) Medication competency records of 16 nurses (RN272, RN273, RN 277, RN94, LPN288, LPN283, LPN147, LPN137, LPN135, LPN133, LPN128, LPN120, LPN116, LPN110, LPN108, and LPN105,) passing medications were reviewed and these 16 nurses were observed to be present on 10/4/16. During interviews conducted on 10/4/16 with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., RN 277 at 10:25 a.m., RN 94 at 8:40 a.m., LPN 288 at 10:15 a.m., LPN 147 at 8:25 a.m., LPN 283 at 11:05 a.m., LPN 147 at 8:25 a.m., LPN 137 at 8:40 a.m., LPN 135 at 8:40 a.m., LPN 133 at 8:32 a.m., LPN 128 at 10:09 a.m., LPN 120 at 9:25 a.m., LPN 116 at 8:26 a.m., LPN 110 at 9:30 a.m., LPN 108 at 8:27 a.m., and LPN 105 at 8:29 a.m., the 16 nurses revealed they were responsible for medication administration, and revealed that all had in-service trainng and passed the competencies identified in the A[NAME] and performed by the administrative staff. The records of the 16 nurses were found to contain evidence of medication competency testing. All of these nurses' records were found to contain evidence of the in-service training and the medication competency testing. An abbreviated medication pass was conducted on 10/4/16. Fourteen medication opportunities were observed with three different nurses, on three different units. LPN 120 was observed between 4:20 p.m. and 4:55 p.m. administering medications to a resident on the West Unit. Four opportunities were observed including a liquid suspension and blood pressure monitoring related to the medication. Beginning at 4:18 p.m., LPN 143 was observed administering medications to a resident on the Upper Central Hall, with 3 opportunities (2 injection and 2 oral medications.) LPN124 was observed passing medications to a resident on the Lower Central Hall beginning at 4:44 p.m. six opportunities, including 1 injection and 5 oral medications, were observed. Methods of administration during this medication pass included PO meds, injections, and liquid suspensions. No errors were identified in the medication pass. A full medication pass, with 25 Medication opportunities, was also observed during the week of 9/26/16 through 9/30/16 as part of the abbreviated and partial extended survey. No errors were identified during that medication pass. 7) Interview with Human Resources staff on 10/4/16 at 11:35 a.m. revealed there were three newly hired nurses in the last week. The personnel and training records of these three staff were reviewed. All three staff had evidence of in-service during orientation on medication administration. Interview with LPN Orientee 308 at 9:40 a.m. on 10/4/16, revealed that she received training during her orientation on correct medication administration. 8) Audits of medication pass observations made by the DON were reviewed. The DON was observed on 10/4/16 auditing two different nurses passing medications. 9) Interview with LPN6 (Admissions Staff) on 10/4/16 at 8:36 a.m. confirmed that the admission paperwork had been amended. She provided a copy of the revised document, which contained the language alleged in the A[NAME]. A letter was also sent to families of current residents after the 9/6/16 incident, informing the families that residents were not to have chemicals stored in resident rooms. 10) Documentation of the 9/29/16 QA meeting was re | 2019-10-01 |
| 401 | HARBORVIEW SATILLA | 115265 | 1600 RIVERSIDE AVE | WAYCROSS | GA | 31501 | 2018-02-15 | 812 | F | 1 | 1 | LMHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and review of policy titled Food Receiving and Storage Facility A failed to assure that food prep equipment was clean and properly stored, maintain the cleanliness of the icemaker and fans, discard expired items, and label and date items in two reach in refrigerators. Facility B failed to assure that items in the dry storage area and in resident pantries were labeled and dated and discarded by the use by date. This included three of three food pantries at facility B and kitchens at Facility A and Facility B. The census for Facility A and Facility B was 161 residents. Findings include: Facility B [DATE] at 11:11 a.m. Brief kitchen tour of Facility B conducted with Dietary Manager revealed the following: 1. There was a box of shredded cheese with an in date of [DATE] but there was not way to determine the expiration date of the cheese. 2. There were eggs in the refrigerator but there was no way to determine the expiration date of the eggs. 3. Two 46 fluid ounce (oz) thickened water containers with an open date of [DATE] and (1) one thickened juice container that was open but did not have an open date on it. The directions for the items stated once opened store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. 4. The storage containers for rice, flour, and meal did not have an open or use by date. 5. In the reach in freezer there were (5) five 32 ounce (oz.) packages of frozen baby carrots with no expiration date. 6. Three bags of diced carrots with an in date of ,[DATE] and (MONTH) 26, (YEAR) listed on the package. 7. Six packages of 12 count hamburger buns with an expiration date of [DATE]. Interview on [DATE] at 11:35 a.m. with the Dietary Manager revealed that there should be a label on each container containing the flour, sugar, and corn meal. She further explained that when the items are placed in the plastic storage container a label should be added to the container identifying the use by date that is listed on the original package. Dietary Manager revealed that all items should be labeled and dated. Futher interview revealed that the buns were delivered on [DATE] and bread is delivered every Tuesday by the Bakery. The Dietary Manager went on to reveal that she typically is the person that would receive the bread at delivery but she was not at the facility on [DATE]. Dietary Manager reported that she would not have accepted the bread on [DATE] since it had an expiration date of [DATE]. Tour of Triana Hall pantry at facility B on [DATE] at 9:08 a.m. with Director of Nursing (DON) revealed the following: 1. Eight 3.5 ounce (oz.) containers of Smart gel Cherry flavored gelatin with an expiration date of [DATE]. 2. Two containers (one with graham crackers and the other with saltine crackers) that did not have expiration dates. Interview with the DON on [DATE] at 9:13 a.m. who reported that nursing staff and dietary check the pantry refrigerators daily for expired items in the refrigerator. Interview with the Dietary Manager on [DATE] at 9:23 a.m. revealed that graham crackers and saltines can be stored up to 6 months. Willet Pantry Tour with DON on [DATE] at 9:30 a.m. revealed: 1. One 20 fl oz Powerade with an expiration date of [DATE]. 2. Five 3.5 oz Cherry Smart gels with an expiration date of [DATE]. 3. Seven 4 fl. oz. 100% Prune juice containers with and expiration date of [DATE] in the refrigerator and (6) six 4 fl oz. containers with an expiration date of [DATE] located on the shelf in the pantry. 4. Three 1.2 oz. boxes of Kellog's Mini-Wheats that did not have an expiration date. 5. One dented can of Campbell's ready to serve Chicken with rice soup. Pavillion Pantry Tour on [DATE] at 9:47 a.m. with DON revealed: 1. One (1) 4 oz. Yoplait Strawberry banana yogurt with a use by date of [DATE]. 2. Four (4) 1.2 oz. boxes of Mini - Wheats with a no expiration date. Interview on [DATE] at 1:25 p.m. with the Dietary Manager who reported that all staff are responsible for checking food in the refrigerator and on the shelves in the pantry to assure food is labeled and not expired. Review of policy titled Dietary revealed the following: Policy Interpretation and Implementation 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. After opening dry foods, they will need to be discarded after 60 days. 7. All food stored in the refrigerator or freezer will be covered, labeled and dated use by date). 13. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees F must be placed in the refrigerator located at the nurses' station and labeled with a use by date. b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Facility A failed to ensure that preparation equipment was clean and properly stored, properly label and date foods in refrigerators, discard expired foods, clean ice maker and maintain cleanliness of fans in kitchen. Facility A: Observation and Interview with Dietary Manager on [DATE] at 11:34 a.m. revealed one mixture stored on a preparation counter uncovered with splattered light colored substances on the blades and guards. The Dietary Manager identified the substances as cake mix. She stated that staff had used the mixture earlier this morning. Observation on [DATE] at 11:36 a.m. of reach in refrigerator #1 revealed the following: 1. One package of open cheese wrapped in wrap partially uncover with no open date or expiration date. 2. Three limes in a bag with no open or expiration date. 3. One small container of cooked gravy with no open date or expiration date. 4. Pureed bake beans in a plastic Tupperware container with no open date or expiration date. 5. Peanut butter and jelly in a plastic Tupperware container with no open date or expiration date. 6. Pimento cheese in a plastic tupperware container with no open date or expiration date. 7. Chicken salad in a plastic tupperware container with open date of [DATE]. 8. Pimento cheese in a plastic tupperware container with open date of [DATE] and expiration date [DATE]. 9. Five pound plastic container of sour cream dated [DATE]. Observation on [DATE] at 11:38 a.m. of Reach in Refrigerator #2 revealed the following: 1. An 8 x 10 pan of Jell-O not dated or labeled. An interview with Dietary Aide (DA) UU at the time of the observation revealed that the jell-o in the square 8 x 10 pan was made on, [DATE] 2. Eleven paper plates of Jell-O fruit square not cover and dated on a cooking sheet Observation on [DATE] at 11:44 a.m. of one ceiling fan facing a preparation counter revealed a greyish substance covering the blades of the fan. During the interview at the time of the observation, the DM identified the greyish substances as dust. She also stated that the fan was not operable and should had been removed from the kitchen area. Observation of one ice machine on [DATE] at 11:42 a.m. revealed a black slimy substances on the top panel of the ice machine. When the Dietary Manager wiped with a white paper towel. The Dietary Manager identified the substance as mildew and stated that she only been with the facility since (MONTH) of (YEAR). She could not recall exactly the date the ice machine was last cleaned. She stated that the maintenance supervisor and one of her staff who is no longer employed did clean the ice machine , a while back. She stated that she will have someone clean the ice machine.She stated that Maintenance is responsible for cleaning the ice machine along with her kitchen staff. She furthere revealed that she did not have a schedule of when the ice machine was last cleaned Interview with the Administrator on [DATE] at at 12:10 a.m. revealed that the facility has another ice machine that the facility staff could use. He stated that he will instruct the dietary staff to discard of all the beverages on the tray carts . He stated that he will have the maintenance staff to clean the ice machine. Interview with the Maintenance Supervisor with the Administrator on [DATE] at 12: 25 a.m revealed that the facility uses a cleaning system Filter Monitor which detects how often the ice machine should be cleaned. This monitor strip is place inside the ice machine and registers on a 6 -12 months timer. Maintenance Supervisor stated that he does not log each time the ice machine is cleaned and was not sure when the last time the ice machine was cleaned. Observation of large fan covered with grey substance attached to the wall in the kitchen located on the in the dishwasher. The fan was facing dishwasher and counter top of the clean dishes. Interview with the Dietary Manager [DATE] at 8:21am revealed the fan is operable . She stated that maintenance is responsible for cleaning the dishwasher.Further reported have no policy on cleaning schedule and for how fans should be cleaned. Review of the facility's policy title Nutrition Services Manua/Food Labeling Reference Guide revealed that staff should keep items in original delivery cardboard cases from vendor whenever possible, put delivery date on cardboard case, put delivery date on individual item(cans, bags, etc.) when removed from cardboard delivery cases. When food iteme is opened and not completely sued writie the open date on the food container. Write a use by date on the food container. Review of policy title Maintenance Policy revealed that ice machines should be thoroughly cleaned and descaled monthly. | 2020-09-01 |
| 5088 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 226 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of policy and procedure, it was determined the facility failed to have an effective system to ensure the implementation of the facility's Abuse and Neglect Prohibition policy for one (1) of twenty-five (25) sampled residents (Resident #1). Licensed Practical Nurses (LPN) MM and LL and Certified Nursing Assistant (CNA) 11 were alleged to have verbally abused and neglected Resident (#1). The alleged abusers worked on the third shift (11 p.m. until 7 a.m.) The facility's corporate office and Administrator had been aware of the alleged abuse since [DATE] but failed to follow the facility's policy and protect the residents from the alleged perpetrators, when they allowed LPN MM, LPN LL and CNA 11 to continue to work and provide direct care to residents. (Refer F155,F281 F223, F225) The facility's failure to implement the facility's Abuse and Neglect Prohibition policy to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Abuse and Neglect Prohibition policy defined Abuse as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance (s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. The facility will report such allegations to the state, in accordance with state regulation. The facility will protect residents from harm during the investigation. Interview with the Administrator on [DATE] at 1:32 p.m. revealed when he became aware of the allegations of abuse/neglect related to the incident involving Resident #1 on [DATE], he contacted the corporate legal department. The compliance team met with the individuals named in the complaint. The Administrator further revealed some employees in the facility had been terminated due to behaviors that could impact resident care. Out of the three (3) staff persons identified in the video, only one, LPN MM, was suspended due to documentation concerns. LPN MM and LPN LL were allowed to return to work after coaching. LPN LL was observed and interviewed while on duty on third shift [DATE] at 5:30 a.m. Review of the Daily Assignment Sheets dated [DATE] through [DATE] indicated that LPN MM was scheduled to work sixteen (16) times. LPN LL was scheduled to work twenty-seven (27) times. CNA 11 was scheduled to work twenty (20) times. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month. | 2019-01-01 |
| 1843 | PREMIER ESTATES OF DUBLIN, LLC | 115495 | 1634 TELFAIR STREET | DUBLIN | GA | 31021 | 2018-01-05 | 625 | E | 1 | 0 | JYBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the Resident Information and Reference Guide, the facility failed to provide bed hold information, in writing, at the time of transfer to the hospital, or within 24 hours, for three residents (A, #2, and #3) of three sampled residents. Findings include: The Resident Information and Reference Guide booklet, provided to residents and/or family on admission to the facility, documented that the facility would provide written information that described the bed hold policy when a resident was transferred to the hospital. The booklet also documented that the facility was required to provide written information to the resident, family or legal representative that specifies duration of bed hold during which the resident would be able to return and resume residence in the facility. Provide written information that specifies bed availability and re-admission practice if the hospitalization or therapeutic leave exceeds the bed hold period under the state plan. Provide notice within 24 hours. The booklet further documented the following procedure in the Bed Hold Requirement and Notification section: [NAME] Complete the Bed Hold Form prior to transferring a resident to the hospital. In cases of emergency transfer, written notification must be provided within 24 hours of transfer. B. Complete the Bed Hold Form prior to the resident leaving the facility for a therapeutic leave C. Provide a copy of the Bed Hold Form to the resident and place a copy in the medical record. However, there was no evidence that the facility consistently provided bed hold information, in writing, at the time of hospitalization or within 24 hours for residents A, #2, and #3. 1. Resident (R) A was hosptalized on [DATE], 10/11/17, 11/3/17 and 11/28/17. Although the facility provided written information of the bed hold policy on admission, a review of the clinical and financial records revealed no evidence that the resident and responsible party were provided with written information on bed hold also at the time of transfer or within 24 hours for the 10/2/17, 10/11/17 and 11/3/17 hospitalization s. A review of the financial file revealed a copy of a letter, dated 11/30/17 mailed to the resident's responsible party notifying them in writing of the bed hold policy. During an interview on 1/5/18 at 1:04 p.m., the current Business Office Manager stated that she mailed out the written notice of bed hold to R A's responsible party for the 11/29/17 hospitalization . However, she did not follow up to ensure that the letter was received. During an interview on 1/5/18 at 1:21 p.m., RA's responsible party stated she never received any written information on the bed hold policy for any of the resident's hospitalization s. 2. Resident #2 was hosptalized on [DATE] and 11/16/17. Although the facility provided written information of the bed hold policy on admission, a review of the clinical and financial records revealed no evidence that the resident and responsible party were provided with written information on bed hold also at the time of transfer or within 24 hours for the 8/6/17 hospitalization . During an interview on 1/5/18 at 1:04 p.m., the Business Office Manager stated she did not have any documentation to show that bed hold information was provided for the 8/6/17 hospitalization . 3. Resident #3 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission, a review of the clinical and financial records revealed no evidence that the resident and responsible party were provided with written information on bed hold at the time of transfer or within 24 hours for the 12/15/17 hospitalization . During an interview on 1/5/18 at 1:04 p.m., the Business Office Manager stated that she notified the resident's responsible party by phone on 12/18/17, of the bed hold policy. The resident and responsible party were not notified in writing. | 2020-09-01 |
| 1030 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2018-12-17 | 770 | D | 1 | 0 | S35E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review the facility laboratory failed to deliver a report of an anti-[MEDICAL CONDITION] drug level, ordered stat (immediately), for one resident (R) C of three sampled residents. Findings include: Review of the undated face sheet in the Electronic Medical Record (EMR) R C was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of R C's quarterly Minimum Data Set (MDS), dated [DATE], section C, revealed R#1 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, signifying severely impaired cognition. Review of section G of the MDS revealed R C required either extensive assistance or was totally dependent on caregivers for all of her Activities of Daily Living (ADLs). Review of a physician's orders [REDACTED]. Review of R C's Medication Administration Record [REDACTED]. Review of a Physical Assessment document, dated 10/31/18 at 11:15 a.m. revealed that Nurse Practitioner (NP) EE examined the resident at that time. Further review revealed NP EE assessed R C as being in a post-ictal (after [MEDICAL CONDITION]) state after sustaining an acute [MEDICAL CONDITION] and that the resident was dazed and mumbling words. Further review revealed NP EE ordered a stat [MEDICATION NAME] level and other lab work and consulted with the resident's physician, who was also the facility Medical Director. Review of the Lab Results Report, dated 12/6/18 at 11:52 a.m., for R C revealed a [MEDICATION NAME] level blood test, among other tests, was drawn on 10/31/18 at 2:38 p.m. and was received by the laboratory on 10/31/18 at 4:47 p.m. Further review of the results revealed the [MEDICATION NAME] level was not available. Review of a Nurse's Note, dated 10/31/18 at 12:40 p.m., revealed a provider was making rounds and noted that the resident was twitching and foaming at the mouth, and was mumbling and staring into space. Further review revealed the provider ordered blood work stat. An interview on 12/5/18 at 4:45 p.m. with the Director of Nursing (DON) revealed that she agreed the [MEDICATION NAME] level result was not in R C's medical record. She stated when a result did not come in a timely manner, especially a stat result, then she would expect her staff to contact the lab and follow-up. She stated it appeared that no follow up had been done. She stated this was not acceptable practice. Review of an email from the DON to the State Survey Agency (SSA) surveyor, dated 12/7/18, revealed the DON had contacted the laboratory provider and was unable to locate or provide the [MEDICATION NAME] level for R C. A telephone interview on 12/17/18 at 2:48 p.m. with NP EE revealed that he knew R C well. He stated he assessed the resident as having had a [MEDICAL CONDITION] on 10/31/18 and ordered a stat [MEDICATION NAME] level drawn as part of his treatment for [REDACTED]. He stated he never got the results of this test. He stated he expected any stat result to be available within 24 hours at the absolute latest. He stated anything less would be unacceptable. He stated he did not follow-up with the lab or the facility to get the missing test result. | 2020-09-01 |
| 1257 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 868 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the Quality Assurance and Performance Improvement policy, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system and ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 residents. An Abbreviated/Partial Extended Survey to investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the facility Quality Assurance and Performance Improvement policy, which was in place, revealed that the policy documented that the purpose of the QAPI program was to continually take a proactive approach to assure and improve the way the facility provided care and engaged with patients, partners, and other stakeholders so that the facility may fully realize their vision, mission, and commitment to caring pledge. The facility's QAPI committee included the Administrator, Medical Director, Director of Health Services (DHS), Clinical Competency Coordinator (CCC), West Wing Unit Manager, Therapy, Admissions, East Wing Unit Manager, Social Services Director (SSD), Activities Director, Business Manager, Maintenance Director, Medical Records Director, Skin Integrity Registerd Nurse (RN), Minimum Data Set (MDS) Coordinator, Dietary Services, Environmental Services and Central Supply/Transportation. The QAPI committee met monthly, at the end of the month. The facility had a system in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record via the Do Not Resuscitate Policy: Georgia and Advance Directive: Georgia policy. However, there was no evidence that this system was routinely monitored through the QAPI process, to ensure that it was accurately and consistently implemented. Review of the facility Cardiopulmonary Resuscitation (CPR), one-person policy, which was in place, revealed that the policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directive or in the absence of advance directives or a DNR order. However, there was no evidence that this system was routinely monitored through the QAPI process, to ensure that, in an emergency situation, nursing staff could respond and implement the policy appropriately. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entries document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a Physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. A telephone interview with the Administrator, Regional V.P., and the DHS on [DATE] at 11:00 a.m., during review of the A[NAME] with the State Survey Agency Regional Director, revealed that the Medical Director had not been involved in the development of the self-imposed IJ plan of action and that a full QAPI committee meeting had not taken place. Additionally, the facility had not reviewed the current Advanced Directive Policy and Procedures as part of the self-imposed IJ action nor had in-services included the CNAs, rather only the licensed nurses had been in-serviced. An interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. He further revealed that he had not been involved in developing the facility's self-imposed IJ plan but was involved and approved the facility's A[NAME] plan. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to QAPI: Facility failed to educate all licensed staff according to the self-imposed plan of correction initiated on [DATE]. Facility failed to audit the Advance Directive system for compliance using the Advanced Directive clinical system checklist. 1. On [DATE] the Administrator, DHS, Area Vice President (AVP), Senior Nurse Consultant (SNC) and Senior Vice President of Clinical Services (SVPCS) met via telephone conference for an ad hoc QAPI meeting to establish interventions for the cited incident. The Medical Director was also called by the DHS on [DATE] and communicated the interventions included in this Allegation of Compliance (A[NAME]). The Medical Director concurred with interventions listed in the A[NAME]. 2. Review of active staff listing was completed to ensure accuracy. Terminated employees will be removed and/or identified on the active staff listing. 3. Newly hired licensed and certified staff will be provided with the education prescribed in the self-imposed plan of correction ([DATE]) will be completed with all licensed and certified staff prior to working, by the CCC or DHS. Completion percentages are noted in each section of the A[NAME]. 4. Newly hired licensed and certified staff will be provided with the education prescribed in the self-imposed plan of correction upon orientation. 5. DHS and Senior Nurse consultant completed and audit of all active resident records on [DATE] and [DATE] utilizing the Advance Directive facility checklist. 6. The Advance Directive Clinical System checklist will be updated upon each new admission or change in advance directive orders by the DHS, Unit Manager, or Social Worker (SSD). 7. Education compliance related to F580, F656, F726, F835 and F868 will be reported to QAPI by the CCC monthly for three months and quarterly thereafter as needed. The Administrator is specified as the staff person responsible for implementing the acceptable plan of correction. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. During an interview and record review with the Administrator on [DATE] at 12:46 p.m. confirmed by reviewing emails and meeting signatures dated [DATE] which included the Medical Director's signature that he had approved the A[NAME]. 2. On [DATE] review of the revised active list of employees to verify the correct number of RNs, Licensed Practical Nurses (LPNs) and CNAs have been educated on the new policies and procedures for verifying Advanced Directives and updating with any change in Physician Order, Code process and procedure, use of the Automated External Defibrillator (AED), and care planning. 3. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that as of [DATE] that RNs, LPNs, and CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart. 4. An interview with the CCC on [DATE] at 12:01 p.m. and the DHS on [DATE] at 1:45 p.m. revealed that both had been educated by the SNC regarding MD notification policy for change of condition on [DATE] and on [DATE]. Review of the sign in sheets confirm the in-services. Verification of sign in sheets for Licensed Nurses confirmed that on [DATE], 20 licensed nursed had completed the in-service on Change of Condition with one nurse on [DATE]. 5. Record review and an interview with the DHS on [DATE] at 1:45 p.m. of the Advance Directives facility checklist dated [DATE] and [DATE] confirmed that all active resident's records had been reviewed to ensure that their Advance Directives were correct. 6. An interview with the DHS on [DATE] at 1:45 p.m. revealed that she currently responsible for updating any new admissions or residents with a change in their Advanced Directives until the new Social Worker (SSD) is hired and educated on the process. 7. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that as of [DATE] that RNs (87.5%), LPNs (100%), and CNAs (88%) had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, care plan updates, new resident or change in condition reporting, new Advance Directive Policy, responsibilities during a code and use of the Automated External Defibrillator (AED). Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the MDS Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. | 2020-09-01 |
| 4585 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2018-09-20 | 656 | D | 1 | 1 | IJ4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to follow the Care Plan related to providing showers for two residents (R) (A and B) out of 37 sampled residents. Findings include: 1. R A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented R A with a Brief Interview of Mental Status (BIMS) score of 11 indicating cognition moderately impaired. R A required two-person physical help limited to transfer only with bathing. Review of the Care Plan for R A reviewed on 6/29/18 documented resident requires supervision and some limited to extensive staff assistance with her Activities of Daily Living (ADL's). Interventions included: Baths Tuesday, Thursday, and Saturday from 3-11 p.m. During an interview on 9/17/18 at 10:02 a.m., R A revealed that the North hall shower room does not work. Resident stated that all residents must use the South hall shower room. Resident stated that she does not always get a shower and she has waited for so long that she washed herself in her bathroom. Interview with Licensed Practical Nurse (LPN) BB on 9/19/18 at 3:30 p.m. revealed that the showers sheets for R A for (MONTH) and (MONTH) (YEAR) could not be located. 2. R B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] documented R B with a BIMS score of 08 indicating cognition moderately impaired. R B required set-up help only with physical part of bathing activity. Review of the Care Plan revised on 8/1/18 documented R B requires supervision with most ADL's. Resident may require extensive assistance with bath/showers at times. Interventions included bath/ shower as scheduled and as needed, assist as needed. Review of the Certified Nursing Assistant (CNA) Skin Assessment Checklist provided by the facility as the shower sheets revealed R B received showers on the following dates in (MONTH) and September: 8/3/18, 8/7/18, 8/14/18, 8/23/18, 8/28/18, 8/31/18, 9/4/18, 9/8/18, 9/11/18, 9/13/18, and 9/19/18. During an interview on 9/20/18 at 3:52 p.m., Director of Nursing (DON) revealed that she expects the care plan should be followed and shower sheets are to be completed and put in her box. DON stated that if showers are missed, they should be offered and completed on the next shift. Review of the facility policy titled Care Plans, Comprehensive Person-Centered revised (MONTH) (YEAR) revealed: a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Cross Refer to F676 | 2019-09-01 |
| 17 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 697 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. On 5/24/19 a Physician's order was again written to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when available 2) Administer [MEDICATION NAME] 10-325mg every six hours, scheduled, for pain and discontinue when [MEDICATION NAME] is available. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. When the on-hand supply of [MEDICATION NAME] 10-325 mg was exhausted, the [MEDICATION NAME] still had not been obtained from the pharmacy. During an interview on 6/3/19 at 12:40 p.m., Licensed Practical Nurse (LPN) AA stated that she phoned the pharmacy on the morning of 5/29/19 (a Wednesday) to check on the status of the [MEDICATION NAME] because she only had two doses of the [MEDICATION NAME] (for 12:00 p.m. and 6:00 p.m.) remaining. LPN AA stated that the pharmacy said they were waiting on a physician signature to fill the prescription. A new Physician's order was obtained on 5/30/19 to administer one Tylenol #4 every six hours as needed until the [MEDICATION NAME] arrived from the pharmacy. A review of the (MONTH) 2019 MAR's and narcotic logs revealed that the resident did not receive the Tylenol #4 until 12:30 a.m. on 5/31/19. Therefore, after the on-hand supply of [MEDICATION NAME] was exhausted and prior to obtaining and receiving the Tylenol #4 medication, the resident missed four scheduled [MEDICATION NAME] pain medication doses on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. During an interview on 6/3/19 at 1:40 p.m. the Director of Nursing (DON) stated that the nurses should be checking and following up on medications that are low at the beginning of the week. | 2020-09-01 |
| 4445 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 520 | K | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy titled, Quality Improvement Committee, the facility failed to maintain a Quality Assurance (QA) program which reviewed, developed, and implemented plans to correct quality deficiencies for all 229 residents living in the facility as of 9/26/16. The facility's QA program failed to: identify and respond to a pattern of failures regarding the identification, protection, and timely reporting of allegations of neglect, abuse, and misappropriation of property. Failed to identify and respond to a failure to have emergency equipment, proper sized cannulas, at the bedside for residents in the ventilator (vent) unit and address staff competencies. Failed to conduct root cause analysis of known problems and implement solutions. The facility was aware of multiple and repeated individual grievances from residents, families, and the resident council regarding staffing, pest control, and dietary services. The census was 229 and the sample size was 52. An abbreviated and partial extended survey was conducted from 9/26/16 through 10/5/16 to investigate complaints, GA 372, GA 244, GA 972, GA 111, GA 424, GA 053, the survey was conducted by Healthcare Management Solutions (HCMS), LLC on behalf of the Georgia State Survey Agency (SSA). The facility was found to not be in substantial compliance with the Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities. The following deficiencies resulted from the facility's non-compliance related to GA 244, GA 972, GA 11, GA 424, and GA 053. The census was 229 residents and the sample size was 52 residents. On 9/27/16 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. The Immediate Jeopardy at F224, F226, F281 and F490 was identified to have existed since 9/6/16, when staff mixed [MEDICATION NAME] with Pine Sol cleaner and administered it to Resident (R) 7, with the resident sustaining burning in her throat and requiring a transfer to the hospital. The facility failed to utilize its resources and immediately report and thoroughly investigate this case of neglect of R7, as well as failed to take necessary actions to protect the resident from the potential for further neglect. On 9/28/16 at 5:30 p.m. the facility's Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. In addition actual harm was cited at F469 S/S:G the failure to control roaches, as well as other insects such as gnats and flies, resulted in psychosocial harm for 2 of 52 sampled residents (R2 and R37), both of whom expressed fear of the roaches which had been seen in their rooms. An acceptable Allegation of Compliance (AoC) was received on 10/3/16, and Healthcare Management Solutions, (HCMS) LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed from all 5 areas on 10/4/16. The Scope and Severity was lowered to the following levels: F224:D, F226:D, F281:D, F328:D, F490:F while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes: After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: Interview with the Director of Nursing (DON) and Administrator on 10/3/16 at 2:42 p.m. revealed that she and the Administrator had shared responsibility for the facility's Quality Assurance and Performance Improvement (QAPI) program. The Administrator stated she was working on a credible allegation to remove immediate jeopardy, and therefore, the Assistant Administrator would be present to assist the DON in answering questions about the QAPI program. Deficient areas that were identified through observations, interviews, and record review during the abbreviated survey were discussed as examples to determine how the facility's QAPI program functioned. 1. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked if the QA committee had identified the failure to identify, immediately report, thoroughly investigate, and take immediate actions to protect residents from potential abuse, neglect, and/or misappropriation. If this area had been identified through the QA process, the DON and Assistant Administrator were asked to provide evidence the QA committee had taken the issue through their QAPI process. (Refer to F224 and F226.) Interview with the DON, during the meeting which began on 10/3/16 at 2:42 p.m., revealed the QA committee did not formally review allegations of abuse and neglect, including the identification of possible patterns and whether there was a need to take action. The DON stated there was no audit of the information contained in each individual allegation to determine possible commonalities, such as the same perpetrator, same shift, and same unit. Likewise, there was no review of allegations to identify systemic problems needing correction, such as failure to identify alleged abuse/neglect/misappropriation of property; failure to immediately report allegations; or failure to immediately suspend alleged perpetrators when an allegation was made. The DON stated grievances were reviewed and provided (MONTH) and (MONTH) (YEAR) documentation, which noted the number and concern areas from the grievances for each unit. Review of this documentation showed a lack of sufficient information to determine if grievances might, in fact, have actually constituted allegations of abuse, neglect or misappropriation of property. In addition, review of this document revealed issues with accuracy. For example: Although the report stated there was a total of 13 grievances for (MONTH) (YEAR), review of the documentation revealed there was a total of 22 grievances (8 on the 300 Unit, 2 on the Central Hall, 5 on West Unit; 6 on Magnolia Terrace, and 1 on the ventilator unit.) Although the report stated there was a total of 16 grievances for (MONTH) (YEAR), review of the documentation revealed there was a total of 22 grievances (9 on the 300 Unit, 9 on the Central Hall, 2 on Magnolia Terrace - 2 and 2 on the Ventilator Unit.) Further interview with the DON revealed the QA committee had not identified any systemic problems with its abuse/neglect prevention program, even though 8 of the 10 incidents reviewed by the survey team, were found to be deficient in at least one of the 7 required components to prevent abuse/neglect (Refer to F226). The DON stated, We had identified some staff reluctance to report. However, she was unable to provide a date when the QA committee had identified this problem. The DON related the problem of reluctance to report had not been taken through the QAPI process. She stated a root cause analysis, per facility policy, of possible reasons for the reluctance of staff to report abuse was not conducted and she verified no action plan was developed to resolve the concern. The DON stated the facility routinely provided training on reporting of abuse; however, this routine training had not been a part of the QAPI process. The DON had no evidence of evaluation of the training to determine whether the training was correcting the problem of a reluctance to report. The DON stated, That's what we're working on now (evaluation of the training), verifying this was in response to immediate jeopardy being found by the survey team. 2. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked how the QA committee was monitoring and identifying potential care concerns in the Specialty Ventilator Unit, which was a separate, stand-along building on the facility's campus (Refer to F328). Interview with the DON revealed the Unit Director of the Specialized Ventilator Unit was a member of the QA committee, as well as an active participant in the facility's morning meetings where individual resident concerns were addressed. She reviewed the sign in sheets and confirmed that he had attended the last full quarterly QAPI meeting on 7/28/16. The DON was informed that the Unit Manager (UM)/Registered Respiratory Therapist (RRT) had informed the survey team of staffing competency concerns for the unit and was asked whether the QA committee had addressed these concerns. Continued interview with the DON revealed the DON was aware of staff training and competency concerns, for staff in the Specialized Ventilator Unit, because the UM shared these concerns during the daily stand up meetings. The DON stated, he told me directly about the problem. However, after a review of QA documentation, she stated, Those concerns didn't make it to formal QA. She reviewed the notes from the meeting and stated that the QA committee looked at audits on long-stay pain (based on Quality Measures) and the use of mittens (hand restraints) on the Specialized Ventilator Unit, as well as talked about one resident with a catheter and one resident with a skin condition. However, she continued and stated, the UM did not tell the formal QA committee that the nurses needed extra training, competencies. The DON was asked if a QAPI plan was developed, since both she and the UM were aware of issues with staff training and competency. The DON stated that in response to the UM concerns, I've got plans in my head but don't have them actually written down about what needs to be done. Further interview with the DON on 10/3/16 at 2:42 p.m., revealed the QA committee had not monitored or identified the failure to have correctly-sized emergency equipment at the bedside for residents on this unit, and was unaware of the problem, prior to identification by the survey team on 9/26/16. 3. Review of Resident council meeting notes beginning 5/5/16 documented residents' concerns about insufficient staffing. Residents' complaints included can't find staff on hall 3-11 shift. Review of resident grievances for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed individual complaints about lack of care from staff, delays in answering call lights, and insufficient staff to meet resident needs. Review of resident council meeting notes dated 9/1/16 revealed additional complaints about insufficient staffing/call light response time. Observations, interviews, and record review during the abbreviated survey, beginning on 9/26/16, revealed that the problem had not been solved and was ongoing (Refer to F353). During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of a QAPI plan which included their analysis of possible root causes of the staffing problem, action plan to correct the problem, evidence of implementation of this plan, and analysis of the results/determination of how well the plan worked. The DON related that the QA committee developed an action plan on 5/27/16 for recruitment and retention of staff, stating that things were done for morale such as a nurse recognition activity in (MONTH) (YEAR). She stated the facility also boosted its orientation efforts, they began completing panel interviews, and fliers were sent out to the community stating the facility was hiring. Further interview with the DON revealed that the facility had not performed a root cause analysis, per facility policy, to determine the basis of the problem before implementing these activities. The DON was asked how the QA committee monitored if these efforts worked well, especially based on the ongoing complaints of lack of sufficient staffing. She related that Human Resources staff maintained retention/turn-over statistics. However, she did not have evidence of this as part of the QA documentation and would have to contact HR to see what information they could provide. Interview with the Human Resources (HR) Director on 10/3/16 at 3:36 p.m. revealed the staff-turnover rate went from 46.6% to 76.5% between (MONTH) (YEAR) and (MONTH) (YEAR). By (MONTH) (YEAR), the staff turnover rate as reported at the (MONTH) (YEAR)sub-QA meeting (monthly meetings held in which the Medical Director was not present, as opposed to the quarterly meetings where she was) had increased to 84.5% The HR Director related that the staffing problem was discussed in QA and determined to be an issue of retention. She stated, It wasn't an issue of hiring new, was retaining old. The HR, DON, and Assistant Administrator were asked to provide evidence of the action plan taken in response to this analysis, as well as evidence of implementation of how well it worked. Although they noted several actions, such as having an employee of the month on 8/15/16 and placing a banner out by the road in front of the facility, stating that they were hiring (also 8/15/16), they confirmed that there was no written action plan or evidence of monitoring to determine if the QA committee's actions had worked. 4. Review of resident council meeting documentation dated 5/5/16, demonstrated residents' concerns about pests. Residents council meeting documentation dated 6/2/16 revealed resident concerns were not resolved. Review of resident council meeting notes revealed the problem of insects continued to be noted as a resident concern in 7/7/16 and 8/4/16 resident council meetings. Observations, interviews, and record review during the abbreviated survey, which began on 9/26/16, revealed that the problem was still ongoing (Refer to F469). During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of a QAPI plan which included their analysis of possible root causes of the problem, action plan to correct the problem, evidence of implementation of this plan, and analysis of the results/determination of well the plan worked. The Assistant Administrator related the facility notified the bug people whenever pests were seen, and provided multiple invoices to show that specific halls/rooms had been treated in response to individual complaints/sightings of insects. However, the Assistant Administrator acknowledged the routine monthly visits, plus additional call-backs as necessary, were what the facility had always done, and were not an action plan in response to the uncontrolled pest problem this year. She stated she was not aware if the ongoing problem of pests had been taken to the QA committee for review, if the QA had completed a root cause analysis to determine why the facility's pest control measures were not working, or if they had developed an action plan in response. Further interview with the Assistant Administrator revealed she would check and provide any additional information she could locate. No further information was provided related to QA activities in response to this problem prior to exit on 10/5/16 at 11:00 a.m. 5. Review of Resident Council meeting documentation, dated 4/12/16 revealed that under old business 15 residents indicated that their previous complaints about staff not serving trays in DR (dining room) timely had not been resolved to their satisfaction. Under new business residents expressed concerns about the 300 Hall not getting first shift ice passed, and not being offered HS (bedtime) snacks. A review of the departmental response form dated 4/15/16 revealed that a QAPI tool done. Will check progress with council and discuss QAPI mtg (meeting). Review of the 5/5/16 Resident Council meeting notes revealed that under Old Business 16 residents stated that trays were still not being served timely. Sixteen residents also indicated their other concerns were not resolved, as they were still not being offered HS snacks, or having ice passed on the first shift. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of the QAPI plans for both the old and new business concerns, including their analysis of possible root causes of the problem, action plan, evidence of implementation of this plan, the QAPI tool mentioned in the response, and analysis of the results/determination of the how well the plan worked. The DON related that she would have to look for information on the QAPI plan and tool that was alleged in the 4/15/16 departmental response. As of 3:34 p.m., the DON was still looking for evidence that a performance improvement plan had been developed as alleged in the response to the resident council. As of 4:49 p.m., the DON related that she could not find a QAPI plan related to the delays in food service. She did state that she had located an audit that identified a problem with residents not receiving bedtime snacks and ice water in a timely manner that was completed on 6/1/16, 1 1/2 months after the departmental response stated the tool was completed. The DON related that in response to the findings of the audit, the facility had done reeducation. Review of the reeducation documentation revealed that the in-services were not completed until 9/5/16 - 9/8/16, 4 months after the residents voiced concerns about snacks. At this time, the DON also provided a documented titled QA/QI HS snacks. The DON described this as a sample audit tool that would be used to monitor the facility's corrective actions. Interview with the DON revealed she had no completed audit tools to verify that staff had monitored that snacks were now being offered and ice water was present for the residents. The Assistant Administrator concluded the interview about Quality Assurance on 10/3/16 at 4:55 p.m. by acknowledging that the QA committee didn't do 'official' written action plans and they had nothing to show to indicate who was responsible for specific actions, who would monitor the identified actions, who would report back to the committee, or what information would be captured, analyzed, and reported to determine if a specific identified care concern had, in fact, been corrected. Review of the policy for Quality Improvement Committee dated (MONTH) 2013 revealed that The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential systemic problems. The committee will implement and systemically evaluate processed to identify problems in order to proactively improve health care deliver . Create systems to provide care and achieve compliance with nursing home regulations. Strive to achieve improvements in specific benchmarks. Utilize data obtained from a variety of sources to identify quality problems, opportunities for improvement, and set priorities for actions. Performance Improvement is a pro-active and continuous study of processed with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix causes of persistent/systematic problems. Performance Improvement Projects will be assigned to focus on a particular problem in one area of the facility or facility wide. Perform root cause analysis, set targets, implement corrections to improve the process. Procedures for this policy included that the QA committee would: Review results of previous audits and identify action plans for any areas needing improvement . Identify quality Improvement opportunities. Assign committee members audits related to any area of concerns Provide training and education as needed to facility staff. ** F328 A[NAME] and Validation The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents on ventilators or with trachs ([MEDICAL CONDITION]) have the potential to be affected. 2. On 9/28/16 residents with trach/vents rooms were checked to ensure emergency equipment to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu (artificial manual breathing unit) bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] were available to bedside by RN/RT and equipment was at residents bedside. 3. On 9/27/16 started reinservicing licensed staff by RN/RT, Director of the [MEDICAL CONDITION] Unit that: Emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. On 9/28/16 in-services continued to be provided by RN/RT, the Director of the [MEDICAL CONDITION] Unit. In-services will continue by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Assistant Director of Nursing Services, RN Unit Manager. In-services will continue until licensed personnel that work in the vent unit have been in-serviced. 100% of in-services will be completed on 10/7/16. 80% of licensed personnel on vent unit have been in-serviced. 4. On 9/28/16 started competencies on licensed staff [MEDICAL CONDITIONS] by RN/RT.[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task. [MEDICAL CONDITION] suctioning included preparation, course of action of suctioning, and completion of task. Competencies will continue until 100% of licensed personnel that work the vent (ventilator) unit have been in-serviced. Competencies will continue to be provided by RN/RT Director of the [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 100% of competencies will be completed by 10/7/16. Licensed staff will not be allowed to work until competency completed 5. [MEDICAL CONDITION] care competency includes: preparation, course of action for cleansing inner cannula, course of action for disposable inner cannula, completion of task. 6. [MEDICAL CONDITION] suctioning competency includes: preparation, course of action for suctioning, completion of task. 7. Nurses that work the vent unit will have a competency checklist completed [MEDICAL CONDITIONS]. Competencies started 9/28/16 by RN/RT. Competencies will be continued by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will continue until licensed nurses assigned to vent unit have been completed. 100% of competencies will be completed by 10/7/16. 8. General orientation - Transitional [MEDICAL CONDITION] Care Unit skills verification to include identification of alarms outside resident rooms, what to do when alarm sounds, will be completed for staff working vent units to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants. Verifications started on 9/27/16 by RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification continued on 9/28/16 aby RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification will continue by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Verification will continue until staff working vent unit are completed. 100% of verifications will be completed by 10/7/16. Staff will not be allowed to work vent unit until verification completed. 80% of staff working vent unit have been completed. 9. During orientation process, newly hired nurses will have a competency checklist completed [MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task [MEDICAL CONDITION] to include preparation, course of action for suctioning and completion of task if working on the vent unit by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 10. Certified nursing assistants working the vent unit will have competencies completed on oral care/bathing/showering of residents with vents and trachs to include: preparation, course of action, positioning, and completion of task by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will be completed by 10/7/16. Certified Nursing Assistants working the vent unit will not be allowed to take an assignment until competency is completed. If certified nursing assistant is pulled from the main building, employee will not be allowed to take an assignment until competency completed. 11. No staff will be allowed to work until competencies and in-servicing are completed. 12. During orientation process, newly hired staff working vent unit will have general orientation-transitional [MEDICAL CONDITION] care until skill verification to include verification to include identification of alarms outside resident room. What to do when alarm sounds. Will be completed by RN/RT Director of [MEDICAL CONDITION] Director or RN Assistant Director of Nursing, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor (sic.) 13. RN Director of Nursing Services or RN Assistant Director of Nursing Services will audit weekly x 4 weeks then monthly x 2 months for emergency equipment at the bedside to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] and ensure emergency kit is placed in wall mount cabinet in resident rooms. Audit findings will be discussed on QA. If problem is noted the problem will be corrected then presented to the Director of Nursing for appropriate action (example 1:1 in-service, disciplinary action.) 14. If a licensed nurse is pulled from the main building to work on the vent unit, employee will be in-serviced on emergency equipment at bedside to be kept in plastic bag in wall counted cabinet in room next to be with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION].[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, course of action for disposing of inner cannula, completion of task.[MEDICAL CONDITION] to include preparation, course of action for suctioning, completion of task. (sic) Any other staff member to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants will be in-serviced on transitional [MEDICAL CONDITION] care unit. Skill verification to include identification of alarms outside resident's room, what to do when alarm sounds. In-service/training will be conducted by RN or RT on the vent unit. The staff member will be in-serviced prior to taking an assignment on the vent unit and on new nurses in orientation. 15. QA meeting was held 9/29/16. Participants were Executive Director, Assistant Executive Director, Social; Service Director, Director of [MEDICAL CONDITION] Services, Medical Director. 16. In-services for emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. Will be completed quarterly on licensed staff. (sic) HCMS on behalf of the State Survey Agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. No action plan was listed in this statement for verification. 2. Documentation of the 9/28/16 room checks were verified during the abbreviated survey. Observation during a tour of the unit on 10/4/16 at 3:30 p.m. found that all resident rooms on the TPCU (Specialized Ventilator Unit) were equipped with the correct size equipment, as well as all other emergency equipment listed in the AoC. Observation of the bedside cabinets containing emergency equipment were checked for 13 residents (residing in Resident Rooms: 101D, 102W, 104D, 104W, 106D, 107W, 110W, 110D, 111W, 111D, 112, 113W, and 115D). Emergency equipment observed including 2 replacements [MEDICAL CONDITION] cannulas (one the same size as what was currently in place for the resident, and one a size smaller, an ambu bag, a pulse ox machine, gloves, gauze, [MEDICAL CONDITION] ties, scissors, vials of Normal Saline, syringe, lubricant, suction catheter and red biohazard bag, was found at each bedside. 3. In-servicing records for all licensed/certified staff working in the vent unit were reviewed, and matched against the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All licensed/certified staff working in this unit was found to have the in-service records alleged in the A[NAME]. Based on interviews with staff and the review of the facility documentation staff are not being allowed to work in this unit without first attending this training, based on interviews with staff, and a review of facility documentation. Interviews were held on 10/4/16 with the following staff: RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., LPN 288 at 10:15 a.m., LPN Orientee 308 at 9:40 a.m., CNA 292 at 9:50 a.m., CNA 166 at 11:55 a.m., CNA 151 at 11:15 a.m., RT 251 at 11:25 a.m., RT 257 11:40 a.m., SW 270 at 9:20 a.m., and PT 309 at 12:20 p.m., as well as the Unit Secretary at 9:10 a.m. The in-service records revealed that each staff received in-service training regarding the general orientation to the TCPU which included but wa | 2019-10-01 |
| 5089 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 281 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of policy and procedure and review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure services provided met professional standards for one(1) of twenty-five (25) sampled residents (Resident #1). Observation of video surveillance of Resident #1's care on [DATE] revealed the resident pushing his call button and calling out Help Me multiple times for symptoms of shortness of breath and chest discomfort. Licensed Practical Nurse (LPN) MM told resident #1 to Stop pushing call light, what is wrong now? Resident #1 replied My heart at 4:46 a.m. LPN MM checked Resident #1's blood pressure at 4:54 a.m. and told Resident #1 that there was nothing wrong with him, he was having anxiety and that he just needed to calm down. Resident #1 continued to summon for help and call out Help Me. Certified Nursing Assistant (CNA) 11 entered Resident #1's room, asked him what he wanted, changed the resident's brief and removed his oxygen nasal cannula. Resident #1 was unresponsive when CNA 11 completed the brief change. CNA 11 called for the nurse and when LPN MM responded CNA 11 said, I came in, he died !. LPN MM appeared to check Resident #1's chest for respirations by placing her ear over his chest. LPN MM and CNA 11 left Resident #1's room, leaving him unattended. They did not perform CPR. CNA 11 returned to Resident #1's room and put the resident's pillow under his head, put his oxygen nasal cannula on his face, covered the resident with a sheet and raised the head of his bed. LPN LL entered Resident #1's room at 6:15 a.m. She placed a back board behind Resident #1 in bed. LPN LL manipulated an oxygen tank but was unable get it operational. The first chest compressions for CPR were performed by LPN LL at 6:34 a.m. The paramedics arrived at 6:38 a.m. Resident #1 was pronounced dead at 7:00 a.m. on [DATE]. (Refer F155, F157, F223) The facility failed to ensure professional staff provided timely necessary care and services to Resident #1 who requested assistance from LPN MM for shortness of breath and chest discomfort. The facility failed to identify a change of condition in Resident #1 and notify the Physician. The facility failed to perform Cardiopulmonary Resuscitation (CPR) when Resident #1 was first identified as having no pulse or respirations. The facility's failure has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. (Refer F155, F223, F282) Findings include: Review of the policy titled Medical Emergency Management, revised (MONTH) 2012 (SSP 0201.00) documented: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff take action to ensure that the residents Airway, Breathing and Circulation are maintained until emergency personnel arrive. Staff is aware of each residents advance directives prior to the administration of cardio [MEDICAL CONDITION] resuscitation. Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure (s) and calls 911. The staff continues to provide care and monitor the resident until emergency personnel arrive. Review of the facility policy titled Changes in Resident Condition documented: The resident, physician and legal representative or designated family member are notified when changes in condition or certain events occur. Assess and document changes in condition in an efficient and effective manner. Provide assessment information to the physician, and provide clear comprehensive documentation Review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act revealed that LPNs may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Record review for Resident #1 revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt dated [DATE] indicated that the resident was a Full Code. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated that his Brief Interview Mental Status Score (BIMS) summary score was three (3), indicating severe cognitive impairment. Shortness of breath and trouble breathing were indicated on the assessment. The resident received oxygen therapy. The facility care planned Resident #1 for Respiratory Problems on [DATE] with Approaches/Interventions that included: Assess for shortness of breath and notify MD of any changes. Observation of the video surveillance was conducted on [DATE] at 1:00 p.m. in the office of the Attorneys representing Resident #1 and his family revealed on [DATE], CNA 11 notified LPN MM that Resident #1 was unresponsive at 5:28 a.m. CPR did not begin until 6:34 a.m. LPN 'LL and CNA 11 could be heard on the video discussing how long they would tell Emergency Medical Service (EMS) they performed CPR. They agreed to report that CPR had been performed on Resident #1 for one (1) hour. The paramedics arrived at 6:38 a.m. Resident #1 did not respond to resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. Review of the Nursing Daily Skilled Summary dated [DATE] at 5:40 a.m. LPN MM documented that she was notified that the resident was not breathing by Resident Care Specialist/ CNA 11. LPN MM documented that Resident #1 had no pulse or respirations. LPN MM documented at 6:20 a.m. that the supervisor talked with the resident's son and informed him of Code in progress then son gave the address and name of mortician to call. LPN MM documented that 911 was called at 6:25 a.m. According to the Nurse's Notes documentation by LPN MM, the paramedics arrived at 6:40 a.m. and Resident #1 was pronounced via telephone by a hospital physician at 7:06 a.m. Interview with LPN LL on [DATE] at 5:33 a.m. revealed that she did not remember the night of [DATE] but that was her with the oxygen tank in the video. LPN LL stated that around that time the oxygen tanks were faulty. The oxygen was coming out where it should not have been. The tanks have been replaced since that time and they don't have the same type regulators. LPN LL said that she did not write any nurses notes about the events of [DATE]. Interview with LPM MM on [DATE] at 10:27 a.m. revealed she recalled that CNA 11 called her into Resident #1's room. CNA 11 told her that something seems to be wrong with Resident #1. LPN MM said that she went into the room, checked his pulse and looked for rise and fall of his chest. She added that Resident #1's skin looked ashen. She stated that when she observed that he wasn't breathing she went to the nurse's station and called LPN LL to tell her that they had to do CPR, then grabbed the chart to check if the resident was deemed a Full Code. She called the son to determine whether Resident #1 was a Do Not Resuscitate (DNR). The son said that he thought resident #1 was a DNR. LPN MM explained further that the Code status was under the Advance Directives tab in the record. She said there must have been a discrepancy with the paperwork. According to LPN MM when the nursing supervisor LPN LL arrived she started the Code and called 911; placed Resident #1 on a backboard and hooked the oxygen up to the resuscitation (Ambu) bag. LPN MM said that she was unsure how long the delay was to actually start the CPR. LPN MM admitted that she did not perform vital signs when she assessed Resident #1 and that there was no step by step documentation of the events of the night. Interview with the Medical Director on [DATE] at 2:30 p.m. revealed that CPR should have been initiated on Resident #1. Resident #1 was a Full Code according to the Medical Director, there was nothing on the chart otherwise. Interview with the Medical Director on [DATE] at 10:26 a.m. revealed that he did not recall being notified of Resident #1 ' s complaint of shortness of breath, anxiousness or chest discomfort on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month. | 2019-01-01 |
| 5084 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 155 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of policy and procedure, review of Emergency Medical System (EMS) records and video surveillance review, it was determined the facility failed to honor the explicit Advance Directive wishes of one (1) of twenty-five (25) sampled residents (Resident #1). Resident #1 had an Advanced Directive which specified he desired to be provided Cardio [MEDICAL CONDITION] Resuscitation (CPR) if cardiac or respiratory arrest occurred. However, on [DATE], LPN MM and LPN LL failed to initiate CPR for Resident #1 when he was found unresponsive at 5:28 a.m. 911 Emergency was not called until 6:25 a.m. LPN LL began chest compressions at 6:34 a.m. EMS arrived at 6:38 a.m. and determined Resident #1 had no pulse and was not breathing. Resident #1 did not respond to the resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. (Refer F223, F281, F282) The facility's failure to ensure residents' Advance Directives were honored has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy for Advance Directives (OP2 0303.00 Release Date: (MONTH) 2005 Chapter: Resident Rights) documented: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law. The facility uses its best efforts to comply with the wishes of a resident as expressed in an advance directive and will not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive and; the facility's copy of the advance directive must be filed in the resident's clinical record. Review of the policy titled Medical Emergency Management, revised (MONTH) 2012 (SSP 0201.00) documented: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's Airway, Breathing, and Circulation are maintained until emergency personnel arrive. Staff is aware of each resident's advance directives prior to the administration of cardio-pulmonary resuscitation. Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure (s), and calls 911. The staff continues to provide care and monitor the resident until the emergency personnel arrive. Record review indicated that the facility admitted Resident #1 in (MONTH) of 2014 with [DIAGNOSES REDACTED]. Review of the Physician's notes dated [DATE] documented that Resident #1 had additional [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt dated [DATE] indicated that the resident was a Full Code. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed resident #1 with no behavioral symptoms. He required assistance for all activities of daily living. His Brief Interview for Mental Status (BIMS) summary score was three (3), indicating severe cognitive impairment. Resident #1 was assessed on the MDS with shortness of breath and trouble breathing. Review of the Nurse's Notes for Resident #1 dated [DATE] at 5:40 a.m. revealed that Licensed Practical Nurse (LPN) MM was called into the resident's room by the Certified Nursing Assistant (CNA) 11. CNA 11 stated Resident #1 was not breathing. LPN MM assessed Resident #1 and found no pulse, no respirations and no blood pressure. Continued documentation revealed that the resident's skin was ashen and mouth was open but his skin was warm to the touch. LPN MM documented at 5:43 a.m. that she called the nursing supervisor and made her aware and called the resident's son. The son stated he thought his father was a Do Not Resuscitate (DNR). LPN MM instructed the son to call the mortuary to pick up the remains of Resident #1. LPN MM then called the Assistant Director of Nursing (ADON) to pronounce Resident #1 dead and notified the Physician on his beeper. Subsequent Nurse's Notes on [DATE] revealed: At 6:20 a.m., LPN MM documented that the supervisor notified the resident's son of a Code in progress and gave him the name and address of a mortician to call. At 6:25 a.m., LPN MM documented 911 was called. At 6:40 a.m., LPN MM documented the paramedics arrived and assessed the resident. The paramedics called the hospital and pronounced the resident at 7:00 a.m. Observation of the video surveillance was conducted on [DATE] at 1:00 p.m. in the office of the Attorney representing Resident #1 and his family. The incident took place on [DATE] and revealed the following events beginning at 4:34 a.m. and ending at 6:38 a.m. At 4:34 a.m. Resident #1 was lying in bed with the over-bed light on, television was audible. Resident #1 appeared agitated and called out Help Me, Help Me and pressed his call button. At 4:35 a.m. Resident #1 was breathing heavily and pushed his call button again, he removed his oxygen by nasal cannula and then tried to replace the nasal cannula himself. At 4:36 a.m. Resident #1 struggled with the nasal cannula and appeared panicky as he tried to put the oxygen by nasal cannula back on. At 4:37 a.m. Resident #1 called out Help Me, Help Me, Help Me . At 4:38 a.m. Resident #1 was heard grunting three times the started struggling with the nasal cannula again. At 4:39 a.m. Resident #1 was panicky At 4:40 A.M. Resident #1 was mouth breathing. At 4:42 a.m. LPN MM entered Resident #1's room and administered medications. Resident #1 said to her My heart. At 4:43 a.m. LPN MM repositioned Resident #1 onto his right side and placed a wedge cushion behind his back. The nurse could be heard telling Resident #1 going to be alright . At 4:44 a.m. Resident #1 was visibly struggling to breathe, however, LPN MM left the room. At 4:45 a.m. Heavy mouth breathing could be heard coming from Resident #1 and he was trying to push his call button. At 4:46 a.m. LPN MM returned to Resident #1's room and said Stop pushing call light, what is wrong now? Resident #1 responded My Heart . LPN MM then responded to Resident #1 Let me get my stethoscope, turned the call light off and left the room. At 4:48 a.m. Resident #1 observed struggling to breath and moaning. At 4:50 a.m. Resident #1 pushed the call button and could be heard moaning. At 4:54 a.m. LPN MM returned to Resident #1's room with the Blood Pressure (BP) machine. She took the resident's BP in both arms. At 4:58 a.m. LPN MM could be heard telling Resident #1 Anxiety, nothing wrong with your heart, blood pressure not elevated, nothing wrong with your heart . Then LPNMM could be heard telling Resident #1 You're having anxiety, that's all, you just need to calm down . At 4:58 a.m. Resident #1 pressed the call button. At 5:03 a.m. Resident #1 could be heard moaning and sounded like he said Help me. At 5:04 a.m. Resident #1 called out Help me, help me. At 5:06 a.m. Resident #1 pressed the call button, again. At 5:23 a.m. CNA 11 entered Resident #1's room and asked What do you want? and changed the resident's brief. At 5:24 a.m. Resident #1 appeared disoriented. At 5:27 a.m. CNA 11 removed Resident #1's oxygen nasal cannula. At 5:28 a.m. Resident #1 appears to be unresponsive. At 5:29 a.m. CNA 11 calls out for help, then proceeds to put the oxygen nasal cannula back into the resident's nose. At 5:30 a.m. LPN MM entered Resident #1's room and asked CNA 11, What happened? CNA 11 threw her hands into the air and replied, I came in, he died ! At 5:30 a.m. both CNA 11 and LPN MM left the room. No CPR was administered. The CNA returned and put a pillow case on the resident's pillow and placed under the resident ' s head. At 5:31 a.m. CNA 11 adjusted the nasal cannula in Resident #1's nostrils, covered him with a sheet and raised the head of his bed. At 5:33 a.m. a conversation could be heard between CNA 11 and Nurse MM that Resident #1 is dead. At 5:52 a.m. CNA 11 washed Resident #1's face and lips, lowers the head of bed and leaves the room. At 6:01 a.m. CNA 11 removed the nasal cannula and pulls the sheet up to Resident #1 ' s neck., then leaves the room. At 6:15 a.m. LPN LL arrived with a CPR backboard. At 6:22 a.m. both LPN MM and LPN LL entered the room, looked at resident #1 but did nothing. At 6:24 a.m. LPN LL began manipulating an oxygen tank. She then gives up on the oxygen tank and laughs. LPN LL proceeded to rearrange the CPR backboard under Resident #1. At 6:27 a.m. it appeared that LPN LL was unable to determine whether oxygen tank is empty or full. She stopped working on the oxygen tank, closes the curtain around resident #1's bed obscuring the picture from the video but not the sound. At 6:28 a.m. LPN LL gives up on oxygen tank and could be heard laughing. At 6:30 a.m. a new oxygen tank was brought to the room and laughing could be heard. At 6:31 a.m. air escaping the round the oxygen tank could be heard. At 6:32 a.m. a comment could be heard to get a missing piece Off the one we had. A different voice responded, Didn't see one on the one we had. At 6:33 a.m. oxygen tubing was placed back on the oxygen concentrator the room. and back on Resident #1. At 6:34 a.m. the first chest compressions were administered x six (6) compressions. At 6:36 a.m. LPN LL performed chest compressions with one hand until the paramedics arrived. At 6:37 a.m. LPN LL was heard asking the CNA 11, How long have I been doing this since? An hour? Asks CNA 11 if they want to say and the hours. CNA 11 responded, An hour. At 6:37 a.m. CPR continued At 6:38 a.m. paramedics entered the room. Review of the ambulance Patient Care Report dated [DATE] documented on page 1 that Resident #1 had a presumed [MEDICAL CONDITION], he had no pulse at 6:40 a.m. and the time of first Cardiopulmonary Resuscitation was 6:40 a.m. CPR was abandoned at 7:00 a.m. Resident #1 was pronounced dead in the field (facility). Additionally, review of the untimed Narrative from the Ambulance report of [DATE] documented that Resident #1 was not breathing and had no pulse. Staff reported unknown downtime. Resident had no response to resuscitation efforts of intubation, intravenous epi and [MEDICATION NAME] as above. Field termination via doctor at hospital at 0700. Review of the Medical Examiner's Inquiry dated [DATE] documented the Cause of Death: Delayed complications of Left [MEDICAL CONDITION], Other Significant Conditions: Coronary Artery [MEDICAL CONDITIONS]. Interview on [DATE] at 10:27 a.m. with LPN MM who was on duty on [DATE] and responded to Resident #1's frequent pushing of his call light revealed that she had been in the room several times to answer his call light. She explained that she was trying to get him to calm down. She did not document each time that she responded to his call light. Nurse MM stated that Yes, I told Resident #1 to stop pushing his call light . LPN MM said that the Resident Care Specialist/CNA called her to Resident #1's room and that something seemed to be wrong with him. LPN MM checked his pulse and looked for rise and fall of his chest. He seemed ashen. LPN MM then went to the nurse's station and called the nurse supervisor to tell her that they had to do CPR. LPN MM said that she did not do vital signs and that when she left the room the CNA 11 was still in the room with the resident. She grabbed Resident #1's chart to check if he was a Full Code then called his son to determine whether he was DNR or not. According to LPN MM the resident's son said that he thought his father was a DNR. LPN MM said that she was not sure if the Code Sheet was on the chart and not sure how long the delay was to actually start the CPR. LPN MM said there must have been a discrepancy with the paperwork. There was no step by step documentation written for that night of [DATE] about Resident #1 according to LPNMM. Further, LPN MM added that when the nurse supervisor LPN LL arrived, she started the Code-911; put him on a backboard, hooked up the resuscitation bag (Ambu bag) to the oxygen concentrator at 2 liters per minute (2/LPM). LPN MM added that the oxygen tank was for use with the Ambu bag but she could not recall why additional oxygen was needed for the Ambu bag. LPN MM said that she was sure that she called the doctor. Interview on [DATE] at 5:33 a.m. with LPN LL revealed that she did not remember much about [DATE] but that around that time the oxygen tanks were faulty and did not work well. The oxygen tanks had been replaced since that time. LPN LL stated that she was the supervisor on the night of [DATE] and was working on a different floor when she was summoned to help the other LPN MM. Interview with the Director of Nursing (DON) on [DATE] at 8:00 a.m. revealed that the residents' code status is normally in the health record in the Advance Directive section. She said the staff must start CPR when residents have no vital signs until the code status is determined. She added that the residents that are Do Not Resuscitate (DNR) are indicated by a red sticker/name tape on their doorjamb. Residents that are Full Code have white name tapes on their doorjambs. The DON said that she expected one staff member to start CPR while other staff check the health record for CPR status. The DON revealed that Resident #1's code status was Full Code as indicated in the (MONTH) 2013 record. Interview with the Director of Nursing (DON) on [DATE] at 11:20 a.m. revealed that the facility follows the American Heart Association guidelines that if there is only one rescuer present they go call 911 then start CPR. The DON could offer no explanation of the events in (MONTH) of 2014 because she was newly hired at the facility. Interview with the Medical Director on [DATE] at 2:30 p.m. revealed that Resident #1 was a Full Code and was to receive CPR. He stated that there was nothing in the chart otherwise. The Medical Director added that CPR should have been initiated until the DNR status was determined instead of looking around for a chart. The Medical Director said that regardless of the situation, start CPR and call 911. An attempt was made to contact CNA 11 by telephone on [DATE] twice without a response. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month. | 2019-01-01 |
| 1029 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2018-12-17 | 658 | D | 1 | 0 | S35E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the Emergency Medical Services (EMS) report, and review of the Georgia Standards of Practice for Licensed Practical Nurses (LPN) 410.10-.02, the facility failed to provide services that met professional standards of quality as evidenced by the duty Licensed Practical Nurse (LPN) failing to provide an accurate, meaningful report to Emergency Medical Services (EMS) personnel during an emergent transfer of Resident (R) C to the hospital and by not reporting this transfer to the resident's physician or Nurse Practitioner (NP) for one resident of three sampled residents Findings include: Review of Georgia Rules of the Board of Nursing 410.10.02 Standards of Practice for Licensed Practical Nurses 1. (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpaitent services, [MEDICAL TREATMENT], speciality labs, home health care, or other such areas of practice. Review of the undated face sheet in the Electronic Medical Record (EMR) for R C revealed the resident was admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. Contnued review of the undated [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], section C, revealed R C to have a Brief Interview for Mental Status (BIMS) score of three out of 15, signifying severely impaired cognition. Review of section G of the MDS revealed the resident required either extensive assistance or was totally dependent on caregivers for all of her Activities of Daily Living (ADLs). Review of a progress note, dated 11/3/18 at 7:10 p.m. revealed the resident's family came in to visit and noted the resident was sleeping. Further review revealed that the family member asked the staff nurse if the resident had been sedated and the nurse stated the resident had not been sedated. Further review revealed that the resident's family member then called the 911 without discussing the call with the nurse and that the resident was transferred to a nearby Emergency Department (ED). Review of a progress note, dated 11/3/18 at 7:58 p.m. revealed a late entry describing an earlier, but unstated time, revealed the staff Licensed Practicial Nurse (LPN) BB wrote that R C was sleeping during rounds but easily aroused. Further review revealed that the resident opened her eyes when her name was called when the paramedics arrived. A telephone interview on 11/29/18 at 2:15 p.m. with LPN BB revealed that she was the resident's nurse the evening that the family member called 911 and took the resident to the hospital. LPN BB stated after she came on duty she visited and assessed R C. LPN BB further revealed that she had no concerns about R C at that time. She stated R#1 was asleep but woke up and spoke to her when she came in the room. LPN BB further confirmed that the resident's family member came in a little later and asked her if R C had been sedated and she told the daughter no. She stated the next thing she knew, the paramedics had arrived and they were putting the resident on a stretcher. LPN BB further revealed that the resident's eyes were open, and that the resident followed all the commotion in the room, but she did not remember if the resident said anything. A telephone interview on 11/29/18 at 2:30 p.m. with the famly member of R C revealed that the family membere had been the caregiver at home for [AGE] years. She stated she got to the facility on a Saturday and found the resident unresponsive. The family membre further stated that the resident's eyes were closed and she did not answer when spoken to. After speaking with LPN BB and asking if the resident had been sedated and the nurse said no; the family member decided to call 911. The family member revealed that once the paramedics got there that the nurse would not talk to the Emergency Medical Technicians (EMTs), telling them to talk to family member, since she was the one who called 911. The family member further revealed that the resident was completely unresponsive and did not open her eyes. On 11/29/18 at 5:30 p.m. the Chief of the county Emergency Medical Services (EMS) was interviewed in his office. He provided the ambulance record for R C and revealed that his number one concern with this incident was that his staff reported that they could not get report from the facility nurse. He stated that this is considered unprofessional behavior by this nurse. He further revealed that the records show that the resident was responsive to painful stimulus only which is assessed by the pinching the patient's arm. He stated if the resident did not respond to voice and pulled away from the arm pinch this would be considered responsive to painful stimulus only. Review of the Prehospital Care Report, dated 11/3/18 at 6:59 p.m., written by EMS staff, revealed that the resident was mentally unresponsive and responsive to painful stimuli only. Further review revealed that when the facility staff was initially questions the nurse said you'll have to speak to the family member since the nurse had not called 911 and walked away. Further review revealed the staff member was relocated and she told EMS staff that the resident was last seen coherent two days ago and was currently being treated for [REDACTED]. Review of the Emergency Department (ED) for RC notes dated 11/3/18 at 19:57 (military time 7:57 p.m.) revealed the resident was seen by the Physician and is unresponsive. Review of ED notes dated 11/3/18 at 7:59 p.m. revealed the resident had Altered Mental Status (AMS) which could have numerous causes and the resident was intubated secondary to agonal respirations (an abnormal pattern of breathing). An interview on 12/5/18 at 3:30 p.m. with LPN BB reealed that she was on duty on 11/2/18 when R Cs family member called 911 and took the resident to the hospital. She stated at first she did not give report to the paramedics and that she left the room. She continued to revealed that she told the paramedic to get the information from the family member then a few moments later she did speak to the paramedic in the hall and had a short conversation. She stated she did not notify the physician or the NP of the resident's transfer to the hospital or provide any transfer documentation to the EMS staff. A telephone interview on 12/5/18 at 4:00 p.m. with the Medical Director revealed that she did recalled R C and was the resident's physician. She further revealed that she did not recall being notified that the resident went to the hospital and that it is expected for nursing to notify her or the NP if any resident went to the hospital. She stated it would be unacceptable to not notify her. An interview on 12/5/18 at 4:45 p.m. with the Director of Nursing (DON) revealed that she expected, as a matter of policy, that report of a resident's condition be given by a nurse, any time, a resident was sent to another facility for any reason. She stated that paperwork should be done and handed to the receiving facility or transport personnel. She stated if a transfer or discharge was emergent, there would not be time to prepare paperwork, but a verbal report should be given and anything else was unacceptable. She also revealed that any time a resident was sent to the hospital that the physician or the NP should be notified. She stated the facility did not have written policy on these matters, per se, but any nurse would know, as a matter of professional standards, to give a proper report and to notify the physician or NP about any transfer or change of condition. An interview on 12/5/18 at 5:05 p.m. with LPN DD revealed that she was a staff nurse. She revealed that any time a resident was transferred to the hospital or another facility the nurse should give report of the resident's condition to the transport facility and provide transfer paperwork to either the transport crew or the receiving facility. A telephone interview on 12/17/18 at 2:48 p.m. with NP EE who works for the Medical Director revealed that he knew R C well. He stated he was not informed of the resident being taken to the hospital until he heard about it the following Monday which was two days later. He stated he, or the on-call NP or the physician should have been notified of any change of condition or transfer to the hospital for any resident. He stated not reporting to him or the doctor would be unacceptable. | 2020-09-01 |
| 317 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2019-06-28 | 580 | D | 1 | 0 | EDYH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the physician and/or the Responsible Party (RP) for two residents out of five, Resident (R)#5 and R#16, after significant change in medical conditions occurred with each resident. Progress note review revealed R#5 presented concerning vital signs on [DATE] at 10:33 a.m. and was discharged to the hospital on [DATE] at 8:37 p.m. Further review of the Progress notes and multiple interviews with facility personnel, including R#5's physician, revealed the physician was not notified of the change in R#5's condition, even after she was discharged to the hospital. Progress note review also revealed R#16 had bloody stool on [DATE] and [DATE]. Further review of the progress notes and staff interviews revealed no evidence the physician or RP were notified. Director of Nursing (DON) interview revealed that the only place a significant change of condition was documented would be in the progress notes. Findings include: 1. Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#5 was admitted to the facility on [DATE] and discharged on [DATE]. Further review revealed her [DIAGNOSES REDACTED]. Review of an admission progress note dated [DATE] at 4:12 p.m. revealed her [DIAGNOSES REDACTED]. Review of R#5's [DATE] at 10:33 a.m. progress note revealed Respiratory Therapist (RT) HH wrote that R#5 had a low oxygen saturation (the amount of oxygen dissolved in the blood) of 84 - 88% and the resident was lethargic. Further review revealed the residents pulse rate was 140 - 155 beats per minute. Further review revealed RT HH notified the nurse. Review of the Mayo Clinic website found at: www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 revealed oxygen saturation (pulse ox) Values under 90 percent are considered low. Interview on [DATE] at 3:45 p.m. with Respiratory Therapist (RT) HH in the surveyor's workroom revealed that RT HH said that he had been an RT for [AGE] years and had been coming to this facility for three years. He stated he recalled R#5 and he had reviewed his note of [DATE] at 10:33 a.m. and agreed he wrote it. He stated the clinical picture was concerning at the time, especially the [MEDICAL CONDITION](high heart rate). He stated he shared his concern with LPN II, who was R#5's nurse that morning. He stated he advised her to check her vital signs in 30 minutes and to call the doctor if they had not improved. He stated he left the building shortly after that and did not know if she checked the vital signs or if she called the doctor. He stated, if the vital signs did not improve, the doctor should have been called. Review of the [DATE] 4:08 p.m. Physical Therapy progress note revealed Physical Therapist (PT) GG wrote he completed 63 minutes of exercise for R#5 and he monitored heart rate and O2 sat during session. He wrote he had checked with the nurse about the possibility of adding medication to bring down heart rate. Review of the [DATE] Physical Therapy Plan of Care revealed the PT GG provided physical therapy for R#5. Further review revealed R#5 had recently been in the hospital with [MEDICAL CONDITION] and declining condition. Further review revealed the family told PT GG R#5's heart rate had been in the 200s when she was in the hospital. Further review revealed R#5's vital signs were 84% oxygen (O2) saturation on room air and 96% with oxygen mask at 6 liters/minute (L/M), 150 beat per minute (BPM) heart rate with an irregularly irregular rhythm, blood pressure (B/P) ,[DATE], and no respiratory rate documented. Further review revealed PT GG listened to R#5's lungs and found diminished breath sounds, and mild bilateral rhonchi (coarse, rattling respiratory sound). Interview on [DATE] at 4:10 p.m. with PT GG in the surveyor's workroom revealed that PT GG stated he recalled R#5. He stated he saw R#5 two times on [DATE] in the morning and in the afternoon. He stated her vital signs, especially her heart rate and oxygen saturation were concerning, but he assessed the resident as able to do physical activity. He stated she was short of breath and had a low blood pressure but often the best way to improve blood pressure is to give the resident some exercise. He stated, looking back on it, the doctor should have been called. Review of the [DATE] at 8:37 p.m. progress note revealed the Assistant Director of Nursing (ADON) wrote she was called to R#5's room and R#5 was in bed with face mask O2 at 6 L/M, respirations 28 - 30, B/P ,[DATE], heart rate 133, temp 98.8, and O2 sat ,[DATE]%. Further review revealed 911 was called and resident left the faciity on [DATE] at 8:45. Review of a [DATE] at 8:36 p.m. physician's orders [REDACTED]. On [DATE] at 3:00 p.m. the ADON was interviewed in her office. She stated she was working late on [DATE] and s a CNA came and said they needed a nurse in R#5's room. She stated she assessed R#5 and called 911. She stated she did not get a doctor's order, nor did she need to. She stated, upon reviewing the progress notes for R#5, that the doctor or Nurse Practitioner (NP) should have been called after the RT assessed the resident at 10:33 a.m. on the morning of [DATE] because it was a significant change of condition and the clinical picture was concerning. On [DATE] at 3:15 p.m. the DON was interviewed in her office. She reviewed R#5's progress notes with the surveyor and stated the doctor should have been called on [DATE] at 10:33 a.m. because the vital signs and clinical picture were concerning. She stated she agreed there was nothing in the record that indicated the doctor, or the NP was called. The DON agreed the clinical picture amounted to a significant change of condition. On [DATE] at 4:45 p.m. Licensed Practical Nurse (LPN) II was interviewed in the surveyor's work room. She stated she had been a nurse for one year. She stated she was R#5's nurse on the morning of [DATE]. She stated she did confer with RT HH that morning about R#5's vital signs. She stated she agreed these vital signs amounted to a significant change of condition and the doctor should have been notified. She stated she did not notify the physician or the RP of the change of condition. She stated she checked the vital signs at about noon and again at about 2:00 p.m. and found the heart rate had improved to about 120 and she was no longer concerned. She stated she agreed 120 was still a high heart rate. She stated she could not remember if she documented those vital signs. An interview was conducted with Registered Nurse (RN) JJ in the surveyor's workroom on [DATE] at 5:00 p.m. She stated she was the Unit Manager of the Rehab Unit where R#5 resided. She stated she had been reviewing the records and there was no question about it: the assessment the RT did on R#5 on [DATE] at 10:33 a.m. revealed a significant change of condition and the doctor should have been notified. She stated she expected her staff to assess accurately and to notify the physician or the NP when a concern was identified A telephone interview was conducted on [DATE] at 3:20 p.m. with the Medical Director (MD). He stated he had worked for the corporate entity for [AGE] years and knew the facility well. He stated he was R#5's physician. He stated the vital signs taken on [DATE] at 10:33 a.m. by the RT were concerning and he should have been called. He stated this would be considered a significant change of condition. He stated he did not recall being notified at any point about R#5's condition on [DATE], or even after she went to the hospital. He stated he expected to be notified of any change of condition for any of his patients. On [DATE] at 10:30 a.m. a telephone interview was conducted with the R#5's son. He stated he was R#5's Responsible Party (RP) and Power of Attorney (POA). He stated on [DATE] at 8:14 p.m. he went to visit R#5 at the facility. He stated he knew the exact time because he had just checked his iPhone. He stated when he entered R#5's room she was gasping for breath and in a bad way. He stated he went out in the hall and asked a staff member to get a nurse. He stated the nurse assessed R#5 and called 911. He stated no one called him at any time on [DATE] to advise him about R#5's condition. On [DATE] at 2:50 p.m. the MD was further interviewed in the conference room. He stated, upon reviewing R#5's progress notes and her admitting diagnoses, the RT should have notified him of R#5's [MEDICAL CONDITION](rapid heartbeat) on [DATE] after his 10:33 a.m. encounter. On [DATE] at 3:10 p.m. the ADON was further interviewed in the Rehabilitation hall. She stated she did not call the doctor after she sent R#5 to the hospital on [DATE]. 2. Review of the undated face sheet in the EHR revealed R#16 was admitted to the facility in (YEAR). Review of the progress notes revealed he was discharged to the hospital on [DATE], where he expired on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of his [DATE] Annual Minimum Data Set (MDS) section C revealed he had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, signifying moderate-to-severe cognitive impairment. Review of section H revealed he was always incontinent of bowel and bladder. Review of section N revealed he received anticoagulant medication. Review of R#16's [DATE] physician's orders [REDACTED]. Review of the [DATE] 9:37 a.m. nurses note revealed R#16 had one bloody stool during the night. Further review revealed that there was not any evidence the physician or RP were notified of this occurrence. Review of the [DATE] 3:54 p.m. nurses note revealed R#16 had rectal bleed on 11p.m. - 7 a.m. shift the night before and the [MEDICATION NAME] was not administered by the ,[DATE] shift. The oncoming nurse was made aware. Further review revealed no evidence the physician or RP were notified of this occurrence. Review of R#16's [DATE] care plan revealed he was at risk for bleeding/bruising related to anticoagulant therapy, rectal fistula, and history of rectal bleeding. Approaches included to monitor for bleeding and to notify spouse of rectal bleeding (sic). On [DATE] at 2:30 p.m. LPN PP was interviewed over the telephone. She stated she only worked as needed (PRN) but had worked for the facility for several years. She stated she recalled R#16. She stated she recalled R#16 having bloody stools but did not recall if she notified anyone about it. On [DATE] at 1:20 p.m. the DON was interviewed in her office. She stated the facility did not have documents that were specific to notifying the physician or RP of a significant change in condition. She stated these notifications should be in the progress notes. On [DATE] at 2:50 p.m. the MD was interviewed in the conference room revealed that he should be notified of rectal bleeding for any resident, whether on anticoagulants or not and that he would consider rectal bleeding to be a significant change. | 2020-09-01 |
| 2279 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2017-11-02 | 157 | D | 1 | 1 | LIXQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the responsible party of a significant change in medication for one resident (R#70). Sample size was 29 residents. Findings include: Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. R#70 was started on [MEDICATION NAME] 0.5 mg every morning and 0.5 mg every night for a total of one mg daily on 4/11/2017. [MEDICATION NAME] is an antipsychotic medication used to treat [MEDICAL CONDITION]. The dose of [MEDICATION NAME] was increased on 5/10/2017 to 0.5 mg every morning and one mg every night. The dose was increased again on 6/14/17 to one mg every morning and two mg every night. The total dose was increased from 1.5 mg daily to 3.0 mg daily, thereby doubling the dose of a high risk medication. While the change in dosage does not constitute a life-threatening condition and is not a new treatment or response to a new condition, it is a signifcant increase (doubling) in total dosage of a high risk medication and exponentially increased the resident's risk of adverse reactions. The facility's practice is to notify the responsible party anytime a medication is changed, started or discontinued and to document that notification in the nurse's progress notes of their computerized records. There is no evidence in the computerized records in Point, Click Care that the daughter was notified. There is no evidence in the hard copy/paper chart of the family being notified as well. In an interview with R#70's responsible party, conducted on 10/31/2017 at 12:35 p.m., revealed that after noting an increase in sedation and discussing it with facility staff, she was informed of the increase in the dosage amounts of [MEDICATION NAME] that R#70 was taking. She stated she had never been informed by the facility staff of the changes in the medication dosage. Furthermore, when she asked the staff to contact the physician regarding the increased sedation she had observed, the staff told her it would be best if she called the physician herself. In an interview conducted on 11/01/2017 at 2:49 p.m. with Licensed Practical Nurse (LPN) BB, revealed that when a medication is added, discontinued or the dosage is changed, the nurses process the order and send it to the pharmacy and they contact the family member to let them know about the change. She stated they document the family contact in the nurse's progress notes in Point, Click, Care, their computerized documentation system. She stated that is the only place they will document the contact to the family member or responsible party. In an interview conducted on 11/01/2017 at 4:35 p.m., the Director of Nursing (DON), confirmed that staff document in the nurse's notes in Point, Click, Care, their computerized documentation system when they notify a family member/responsible party of any changes in condition, new orders, or changes in orders. Additionally, in an interview conducted on 11/02/2017 at 11:05 a.m. via telephone with the Pharmacist, she stated she considers the change from a total of 1.5 mg of [MEDICATION NAME] every day to a total of 3 mg [MEDICATION NAME] every day a significant increase in dosage, doubling the amount each day. The pharmacist stated that typically the physician will titrate (or change) the dosage increases, usually in 0.5 mg increments. She verified the physician's orders [REDACTED]. This order was filled from (MONTH) 10th - (MONTH) 9th; she then notes he was increased to one mg at bedtime from (MONTH) 10th - (MONTH) 13th. Then there was an increase to a total of 3 mg per day (one mg in the AM and two mg at bedtime) (MONTH) 14th. She stated the risk for adverse reaction increases exponentially with the increase in dosage. A review of a nurse's progress note dated 4/10/17 notes the nurse notified the RP (responsible party) about the new order for [MEDICATION NAME] 0.5 mg from [DOCTOR]. Review of a nurse's progress note dated 5/10/17 notes a new order increasing [MEDICATION NAME] to 0.5 mg every AM and one mg at bedtime. There is no evidence of any documentation regarding any type of communication with the responsbile party regarding the change in medication dosage. Review of a nurse's progress note dated 6/14/17 reveals R#70 was seen by the physician and the [MEDICATION NAME] dosage was increased to one mg every morning and two mg every night. There is no evidence of any documentation regarding any type of communication with the responsbile party regarding the change in medication dosage. | 2020-09-01 |
| 1253 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 658 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, review of the Georgia Board of Nursing Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, review of the Standards of Practice for Registered Professional Nurses: ,[DATE]-.01, the facility failed to provide adequate supervision of certified nursing staff regarding the initiation and cessation of cardiopulmonary resuscitation (CPR) during an emergency situation for one resident (A), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the Georgia Board of Nursing Rule ,[DATE]-.02: Standards of Practice for Licensed Practical Nurses, 1) The practice of license practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not limited to the following: e) Participating in the management and supervision of unlicensed personnel in the delivery of patient care. Review of the Georgia Board of Nursing ,[DATE]-.01: Standards of Practice for Registered Nurses, 2. (a) 3. Plan care which includes goals and prioritized nursing approaches, or measures derived from the nursing diagnoses; (b) 3. Communicate, collaborate and function with other members of the health team to provide optimum care; 8. Assign and supervise only those nursing measures which the nurse knows, or should know, that another person is prepared, qualified, or licensed to perform; 9. Retain professional accountability for nursing care when delegating nursing intervention. The facility had a Do Not Resuscitate Policy: Georgia policy. The policy documented that CPR will be performed on all residents without a DNR order unless it is determined that CPR is not medically justified as determined by two nursing personnel, one of whom must be licensed. Not medically justified is defined to mean that when all of the conditions listed below are true, CPR will not be initiated, even if the resident does not have a DNR order documented on the chart, until the physician is notified, and orders are given to administer CPR. 1. Resident was found with no visible respiratory efforts 2. Resident was found with no vital signs 3. Resident was found unresponsive to verbal or painful stimulation. 4. Resident was found with fixed, dilated, and non-reactive pupils. 5. Resident was found with skin cold to touch. 6. Resident's decline in condition is sudden and not witnessed, and the resident is found without any signs of life. The facility also had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. The policy included to administer 30 chest compressions at a rate of 100 to 120 per minute. Push hard and fast. Open the airway and give 2 ventilations. Then find the proper hand position again and deliver 30 more compressions. Continue chest compressions until the emergency response team arrives or another rescuer arrives with a defibrillator or an automated external defibrillator (AED). Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a physician's orders [REDACTED]. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent nurse's note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., Emergency Management Services (EMS) personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. During an interview on [DATE] at 11:37 a.m., CNA HHH stated that R A could get up on his own and would normally get up on his own and then call for assistance with his oxygen. On [DATE] around 5:00 a.m., she responded to the resident's call light. The resident was in the bathroom and said he needed his oxygen, so she applied is oxygen tubing and exited the bathroom. She stated that the resident did not complain of shortness of breath. She responded to his call light a second time when she noticed it on, above his door, when she exited another resident's room. R A was lying in the bed and stated that he had wanted some assistance with pulling up his pants but had already pulled them up and was in the bed. CNA HHH stated that the resident had his oxygen on, did not complain of any shortness of breath and she left the room. CNA HHH stated a little later she responded to his call light a third time. He was in bathroom again, on the commode, and said he needed his oxygen, so she applied his oxygen tubing. She stated that he did not complain of any shortness of breath and that she reminded him that his oxygen tubing would reach into the bathroom, that he did not have to take it off when he went to the bathroom. CNA HHH stated that she exited the room and not even five minutes later, R A turned his call light on again. She went back into the bathroom and observed him lying on the floor beside the toilet, asking for help to get up. CNA HHH stated that she noticed at that time that his right arm was a grayish color and that was different for R [NAME] She stated that she left the resident's room to get Licensed Practical Nurse (LPN) OO. Additional help was also obtained from CNA QQ. CNA HHH stated that the resident remained alert but then became quiet while they were attempting to remove the resident from between the commode and the wall and he was unresponsive when they were able to get him out. CNA HHH stated that LPN OO instructed her to call the code so she left the room to call the code and obtain the crash cart. CNA HHH stated that when she returned to the room LPN OO was trying to obtain vital signs on the resident but there were none, so she (CNA HHH) initiated chest compressions on R A, and that LPN OO left the room to call the code again because LPN PP had not heard the first call, although LPN OO did not return to the resident's room. CNA HHH stated that she continued to provide chest compressions until she overheard LPN PP, who had arrived on the unit, state that the resident was a DNR, and then she stopped providing chest compressions. CNA HHH stated that she did not receive any supervision, guidance or instructions from the LPN's on initiating or stopping CPR. CNA HHH stated that she was not aware that once she started CPR, she could not just stop. The DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled. During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. There was no evidence that R A's condition met the criteria of not medically justified, as documented in the facility's Do Not Resuscitate Policy. There was also no evidence that an attempt was made to assess R A's Advance Directive status prior to CNA HHH initiating CPR and no evidence that supervision and guidance was provided to the CNA by the LPN's regarding initiating and cessation of CPR. In addition, facility staff failed to continue to provide continued chest compressions until EMS arrived, as documented in the facility's CPR, one-person policy. There was no evidence that an attempt was made to verify the accuracy of the DNR form maintained in the MAR book and Resident A's Advance Directive status, through a review of his clinical record, prior to the cessation of CPR. During interviews on [DATE] at 4:24 p.m. with Licensed Practical Nurse (LPN) OO and on [DATE] at 7:28 a.m. with LPN PP, both of whom were present and responded to the resident's change in condition on [DATE], both confirmed that they did not look for Advance Directive information in the resident's chart and neither instructed CNA HHH to begin or stop CPR. In addition, there was no evidence that the DHS verified R A's Advance Directive status prior to pronouncing his death on [DATE] at 7:09 a.m. During an interview on [DATE] at 1:45 p.m., the DHS confirmed that she did not verify the resident's Advance Directive status prior to pronouncing his death on [DATE]. During an interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate advance directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a Physician order [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to competency of staff: The facility failed to ensure that all licensed staff were competent regarding the protocol for CPR. The LPN failed to supervise certified staff members during CPR. LPN exited the room where certified staff were performing CPR to page for additional nursing staff, review the DNR listing in the Medication Administration book and call 911 and failed to return. 1. LPN OO will be terminated on [DATE] 2. Licensed and certified staff were educated by the DHS and Clinical Care Coordinator (CCC) from [DATE] through [DATE] including one newly hired staff on [DATE], on Do Not Resuscitate Policy: Georgia and Advance Directives: Georgia. Fourteen of 14 LPN's were educated as of [DATE] (100%), seven of eight RN's (87.5%) were educated as of [DATE], and 29 of 34 active CNA's completed education as of [DATE] (85%). 3. All newly hired licensed and certified staff will be educated during orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA, and as-needed work status will not work until this education is completed. 4. The facility DHS, Nurse managers and/or Administrator will conduct mock code drills including AED function/usage, and the supervisory role of the nurse during the code, weekly for four weeks and monthly for two months. The results will be communicated by the DHS or Administrator at QAPI monthly for three months. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of the personnel file for LPN OO on [DATE] confirmed a separation noticed dated [DATE]. 2. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that on [DATE], [DATE] and [DATE] that 100 % of the RNs, LPNs, and that 29 CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, change in condition, nursing runs the code, that once CPR is started then it cannot be stopped without a doctors order and that mock code procedure had been put into place. The facility provided evidence that four mock drills had been conducted by [DATE], with sign-in sheets and evaluation had been completed. The mock codes drills will continue. 3. An interview with the CCC on [DATE] at 1:20 p.m. confirmed that one new staff member had been hired on [DATE] and verified through sign-in sheets that the new staff person had been educated. The CCC confirmed that any new staff, or any staff, not already in-serviced, would be in-serviced on the new policy and procedure for checking the Advanced Directive Status, change in condition, and nursing runs a code and that once CPR is started it cannot be stopped without a doctor's order chart prior to working. 4. Observation on [DATE] at 11:50 a.m. of a Code Blue being announced in a resident's room over the intercom. Observation of the mock drill in progress by the surveyor revealed that the DHS and Corporate Nurse Consultant were guiding the nurses and CNA's on roles which included: providing CPR and rescue breathing on CPR mannequin, role delegation, step by step instruction on use of AED (Automated External Defibrillator) use, continuation of CPR until mock EMS arrival to take over, notifying the MD, family and charting afterwards. The DHS made a point to clarify that licensed nurse oversees the code, should be in the room with the resident. The mock drill list was reviewed with staff. Staff present ran smoothly through the drill. Review of the Mock Code Drills education checkoff sheet revealed the following: date, time, number of participants (see sign in sheet), nurse in charge on scene, nurse assigned duties, crash cart present and AED utilized and reviewed, scribe assigned and writing, paged code, chart brought to room or reviewed for code status, 911 called, MD and RP called and documented in chart, crash cart restocked and sealed. Record review of Mock Drill form dated [DATE] and interview with the DHS on [DATE] at 1:45 p.m. confirmed the Mock Drills will be conducted weekly for four weeks then monthly for two months. The DHS confirmed that she will present the findings to the QAPI committee monthly. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed knowledge that the licensed nurse oversees the code and should not leave the room during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They were aware that the licensed nurse is in charge of the code and should give direction to them during the code. They confirmed participating in a Mock Code Drill. | 2020-09-01 |
| 604 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2019-05-28 | 658 | D | 1 | 0 | F4GX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, review of the Georgia Nurse Practice Act, licensed nursing staff failed exercise competent independent judgement by not verifying the location of one resident (A) to ensure their safety, from a total sample of 19 residents. Findings include: Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.02 Standards of Practice for Licensed Practical Nurse addressed Rule 410-10-.02 (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or health care facilities in area of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. (f) Performing other specialized tasks as appropriately educated. 2. Responsibility: Each individual is responsible for personal acts of negligence under the law. Licensed practical nurses are liable if the perform functions for which they are not prepared by education and experience and for which supervision is not provided. The facility had a job description for Licensed Practical Nurses (LPN). The job description included an essential supervisory function of exercising independent judgement. The job description acknowledgement was signed by LPN AA on 10/19/15. However, LPN AA failed to exercise competent independent judgement on 5/12/19 by not verifying the location of Resident (R) A, when the resident was not in her room. A 5/13/19 9:09 a.m. Nurse's Note documented that LPN AA was summoned by nursing staff on D hall that RA was lying on the ground in the courtyard. The resident was assisted back to her room and assessed. Review of facility investigation information revealed that the resident was observed on the ground in the courtyard on 5/13/19 at 7:10 a.m. by R#7 from his bedroom window. R#7 alerted nursing staff, who responded and assisted RA back to her room for further assessment and interventions. A further review of the investigation information revealed that it was determined that the RA had been outside, in the courtyard overnight. An interview on 5/20/19 at 10:33 a.m., LPN AA confirmed that she was assigned to RA from 5/12/19 at 7:00 p.m. through 5/13/19 at 7:00 a.m. She stated that she did not see RA during her shift and assumed she was out with her family for Mother's day. LPN AA further stated that she looked at the Leave of Absence (LOA) book to see if the resident had been signed out, and she had not been signed out as leaving the facility. She assumed the resident left with her family without signing the LOA book. However, LPN AA did not call the resident's family to verify her assumption. During an interview on 5/15/19 at 2:55 p.m. the Administrator stated that when LPN AA did not see RA in her room and the LOA book had not been signed out, she should have looked for the resident and if not found, should have called a code pink (missing person code). Cross refer to F689 | 2020-09-01 |
| 4404 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 501 | J | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the Medical Director failed to assure care was provided that met current standards of practice in areas including resident-to-resident abuse and use of [MEDICAL CONDITION] medications. The facility's failure to ensure residents were protected from further physical abuse by R#39 was determined to be likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/8/16 and determined to first exist on 10/23/16, when R#39 first threatened R#56 with harm using a wire clothes hanger. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 12/8/16 at 2:55 p.m. An acceptable AoC was received on 12/10/16 and the surveyors validated the Immediate Jeopardy was removed on 12/10/16 as alleged. The deficient practice remained at a D (isolated potential for more than minimal harm) scope and severity while the facility developed and implemented the Plan of Correction and the facility's Quality Assurance Committee monitored the effectiveness of the systemic changes. Findings include: During the annual recertification survey and complaints investigation from 12/5/16 to 12/10/16, the facility was found out of compliance with regulatory requirements regarding prevention of resident-to-resident abuse and use of [MEDICAL CONDITION] medications. Cross-reference F222: Chemical Restraints - the facility failed to ensure resident (R) #56 and R#83 were not chemically restrained. The facility administered an array of [MEDICAL CONDITION] medications, including PRN (as needed) injections of medications and multiple medications from the same drug class, to manage residents' behaviors for staff convenience. [DIAGNOSES REDACTED]. The rationale and effectiveness of the medications was not consistently documented. Cross-reference F223: Physical Abuse - the facility failed to ensure that R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm. R#39 threatened R#56 with harm from a wire clothes hanger on 10/23/16. On 12/5/16, R#39 was observed hitting R#56 with a wire clothes hanger. The facility responded with an intervention to remove all wire clothes hangers from R#39's possession. On 12/8/16, a wire clothes hanger was observed in R#39's room. The nursing staff assigned to work with R#39 were unaware of the intervention to remove wire clothes hangers from his possession. Cross-reference F226: Abuse Policies and Procedures - the facility did not ensure R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm and failed to conduct a criminal background check for one of two active nurse managers reviewed. Cross-reference F280: Care Plan Revision - R#39's care plan was not revised to reflect an incident of threatening another resident; R#81's care plan was not revised to reflect the resident's positioning needs; R44's care plan was not updated with the development of a new pressure ulcer; R27's care plan was not revised to reflect the resident's current needs for help with activities of daily living; R#83, and R#22's care plans were not updated with non-pharmacological interventions to address behavioral symptoms; and R#51's care plan was not reviewed quarterly as required. Cross-reference F329: Unnecessary Medications - the facility failed to ensure the drug regimen was free of unnecessary drugs for R#88, R#40, R#83, and R#22. Cross-reference F428: Medication Regimen Review - the facility failed to ensure the drug regimen recommendations from the pharmacist were acted upon for R#88, R#22, R87, and R#40. Cross-reference F490: Administration - the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to ensure new interventions to address resident-to-resident physical abuse by resident (R) #39 were communicated to all staff and a system was implemented to ensure the intervention was carried out to prevent further incident and to maintain substantial compliance with Federal requirements at 42 Code of Federal Regulations (CFR) Part 483, Subpart B - Requirements for Long Term Care Facilities. Cross-reference F520: Quality Assurance Activities - the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to resident-to-resident abuse and use of [MEDICAL CONDITION] medications The 5/22/15 Medical Director Agreement documented: Medical Director shall perform administrative services at the facility as reasonably appropriate to the position of a medical director including but not limited to the following services: a. Provide general medical decision input and support to the administration of the community; b. Review and assist to implement resident care policies and procedures c. Coordination of medical care; d. Participate in the facility's quality assurance process, to ensure the quality of medical and medically related care, including reviewing and signing all incident reports; e. Provide on-call availability and respond to medical or regulatory or other emergencies; f. Participate in the development and presentation of education programs g. Participate, as appropriate, in matters of employee health, and promotion of the health, welfare and safety of employees; h. Help articulate the facility's mission to the community and represent the facility in the community; (and) i. Serve as patient advocate, as needed, to secure medically necessary services . Medical director agrees that the services provided under this agreement shall be provided in compliance with all applicable federal, state, and local laws, rules, and regulations, and all applicable rules and regulations of any third-party payers covering medical director's services hereunder. Exhibit A of the Medical Director Agreement went on to describe the Medical Director's duties: 1. Provide medical decision input and support to the administration of the community a. Participates in the development and review of resident care policies, as well as policies regarding services of physicians and other professionals; b. Participate in meetings with the administrator and director of nursing to discuss clinical and administrative issues, specific patient care problems and professional staff needs for education or consultants. Offer solutions to problems and identify areas where policy should be developed; c. Assists in the preparation for, review, and respond to federal, state, and local surveys and inspections; d. Advise administration of current developments regarding patient care and new treatment modalities; (and) e. Communicate on a regular basis with the administration regarding actions, recommendations and concerns . 4. Participate in the facility's quality assurance process, to ensure the quality of medical and medically related care . (and) 6. Participate in the development and presentation of education programs. On 12/10/16 at 2:38 p.m., the Administrator stated the Medical Director had not provided the facility with any education regarding behavior management, prevention of abuse, or use of [MEDICAL CONDITION] medications. Regarding the identified failures with [MEDICAL CONDITION] medication use, she stated, I've talked to (the Medical Director) several times about the lack of follow up with ([MEDICAL CONDITION] medications) without any progress. On 12/9/16 from 4:00 p.m. to 5:00 p.m., the Medical Director was interviewed. He stated he attended most monthly QA meetings, where all clinical issues were reviewed. He stated the committee attempted to identify any patterns or trends in their data and focused on those for further review. The Medical Director stated his goal was to reduce the use of [MEDICAL CONDITION] medications in the facility, as their use of these medications went up dramatically with the influx of new residents with behavioral issues or psychiatric diagnoses. The Medical Director stated his job was to show a medication was necessary and clinically appropriate or to discontinue the use of the medication. When asked if he reviewed behavior documentation, frequency of use and reasons for use of PRN (as needed) medications, or the effectiveness of the medication regimen, the Medical Director stated, The pharmacy consultant is good about looking at that, then sends me recommendations to follow up. The Medical Director stated if the pharmacist made recommendations regarding a resident's medication regimen, he would document the rationale for accepting or declining the recommendation on the pharmacy recommendation report. The Medical Director stated, In the past, [MEDICAL CONDITION] medication use was not one of his major focus areas, but within the last year the clientele at the facility had become more aggressive and had more prevalence of polypharmacy, so this was a new focus over the last year. The Medical Director stated he had not provided any education with facility staff regarding management of aggressive or problematic behaviors, [MEDICAL CONDITION] medication use, or monitoring for effectiveness of [MEDICAL CONDITION] medications. Regarding R#39, the Medical Director stated he has known the resident for a long time and knows him to be a very sweet fell ow. He stated the altercation on 12/5/16 was not his usual behavior and he had never witnessed R#39 be aggressive with others. The Medical Director stated he was unsure if the verbal abuse witnessed on 10/23/16 in the dining room was reported to him. The Medical Director stated he had never discussed the vulnerable residents in the building in order to identify those at risk and protect from aggression from other residents. He stated, That's a very good idea. The Medical Director added he was ultimately responsible for the clinical care of all the facility residents. He stated, If the resident's primary physician is not available, then I am available for all staff to contact me with any concerns. On 12/8/16 at 2:55 p.m., the Administrator and Director of Nursing (DON) were alerted to the presence of an Immediate Jeopardy situation related to R#39's continued access to wire hangers and lack of staff education related to safety interventions for R#39. The facility implemented the following actions, per their credible AoC, to remove the Immediate Jeopardy: Step 1: On 12/8/16 at approximately 3:10 p.m., the resident determined to be the aggressor was placed on one on one supervision and facility social worker began seeking inpatient stabilization services for resident. At approximately 11:45 a.m. and 3:15 p.m. on 12/8/16, the resident's room was checked to ensure that no other potentially dangerous items were present. Step 2: On 12/8/16, the Administrator will purchase adequate plastic clothes hangers and on 12/9/16 at approximately 8:00 a.m., the Housekeeping and Laundry Supervisor will begin converting all resident closets to plastic clothes hangers and all wire hangers will be placed in dumpster for removal. Step 3: At approximately 5:30 p.m. on 12/8/16, the resident was transported to (the behavioral health hospital) for direct admission for stabilization. On 12/8/16 at approximately 5:15 p.m., the Care Management Team met and reviewed residents in house to determine any other at risk residents and no other risks were identified. The Administrator and/or designee will educate all staff immediately with mandatory in-servicing regarding the removal or wire coat hangers on 12/8/16 and will be continued until 100% completion. In-service is mandatory and wall (sic) employees will participate prior to reporting to work. As of 12/10/16 at 1:30 p.m., the facility has 96% completion for removal of wire coat hanger in services the facility has one LPN, one RN, and one dietary employee remaining to be in serviced the DO and will in-service staff concerning resident abuse and managing adverse behaviors, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 12/10/16. As of 12/10/16 at 1:30 PM, the facility is at 93% for the abuse in servicing we have remaining to nursing assistance to LPNs one RN and one dietary staff and 2 to inservice. Step 4: A quality assurance audit tool for physical/verbal or aggression was created on 12/9/16. Incidents of physically/verbal or aggressive behavior will be audited by the DON and or her designee using the quality assurance audit for physical/verbal or aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective on 12/9/16; any findings of noncompliance will be presented to the quality assurance committee monthly to determine if additional action is needed ongoing. Residents determined to be the aggressor will be placed on every 15 minute visual monitoring until the resident is stabilized or transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered in aggressor as of 12/9/16 and monitoring will occur every 15 minutes until the residents are stabilized or transferred to an inpatient psychiatric behavioral unit for evaluation. If the resident is the victim of the physically/verbal or aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 12/9/16 to include signs of symptoms of abuse, i.e., excessive crying, bruises, trembling, scratches, withdrawal, pain(.) If the resident is the victim of a physically/verbal or aggressive behavior the social services department will be notified and they will monitor the residence (sic) psychological wellbeing (sic) concerned in the resident as well as the resident's reaction to his or her involvement in the investigation social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 12/9/2016. During the seven-day period of visual monitoring if the resident exhibits physically/verbal or aggressive behavior without injury, to either party, every 15 minute, visual checks will be resumed until the resident is determined to be stabilized by the Care Management Team or transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually(/)physically aggressive behavior results in injury to either party, one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 12/9/2016(.) All residents with physical/verbal or aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the care management meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 12/9/2016. All residents with physical/verbal or aggressive behavior will continue to be evaluated by the facility contracted psychiatric group during their visits. The Administrator and director nurses (sic) will continue to be notified of any reports of physically or sexually aggressive behaviors immediately. The nursing staff will continue to complete incident reports for incidence (sic) of abusive behavior. Effective 12/9/2016(.) Care plan coordinator will be educated to implement revision of approaches and interventions to the plan of care related to both physical/verbal and aggressive behaviors by 12/9/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses or her designee as part of the weekly care management meetings. This education was completed at 100% on 12/9/16. Any resident that were not updated will be updated immediately during the weekly care management meeting effective 12/9/16(.) The surveyors validated the implementation of the AoC as follows: Step 1: R#39 was observed with one-to-one supervision from approximately 3:15 p.m. to 5:35 p.m., when the resident was sent out to the behavioral health hospital. The order to send the resident out and the Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health) were reviewed. R#39 had not returned to the facility by the close survey on 12/10/16 at 6:00 p.m. Step 2: On 12/9/16, the housekeeping staff was observed to replace all wire hangers in residents' rooms with plastic hangers. On 12/10/16, a 100% resident room audit was conducted and no wire hangers were observed. Step 3: The Care Management Team audit of residents at risk for physical aggression was reviewed. The in-service records from trainings on removal of wire coat hangers and on resident abuse and managing adverse behaviors were reviewed; 96% completion of the wire hanger removal in-service and 93% completion of the abuse and adverse behaviors in-service was verified as of 1:30 p.m. on 12/10/16. Interviews were conducted with the Social Services Director (SSD); Activity Director (AD); CNAs AY, AT, AG, AH, and AI; LPNs AE, AO, AF, and AB; Registered Nurses (RN) AB and AD; and the receptionist on 12/10/16 from 11:00 a.m. to 12:00 p.m., all of which confirmed the education was received and understood. Step 4: The quality assurance Audit Tool was reviewed, and will be completed going forward for any incident of resident-to-resident aggression. The education record of the MDS Coordinator (care plan coordinator) was reviewed on 12/10/16 and confirmed as completed. R#39 had not returned to the facility as of the survey exit on 12/10/16 at 6:00 p.m. | 2019-11-01 |
| 1255 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 835 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility administration failed to ensure effective monitoring of the Advance Directive system and failed to ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Position Description for the job title of Administrator. The description included that the purpose of the job was to direct the day-to-day functions of the nursing center in accordance with Federal, State, and local regulations that govern long-term care centers, and as may be directed by the Area Vice President, to provide appropriate care for residents. The position description also included a key responsibility of the ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Review of the facility Quality Assurance and Performance Improvement (QAPI) policy revealed a QAPI meeting reference guide documented that the Administrator was responsible for preparing and/or assigning specific information listed in the agenda for the QAPI meeting. During an interview on [DATE] at 12:46 p.m., the Administrator confirmed that she did oversee the QAPI meetings. Review of the facility policy which was in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record via the Do Not Resuscitate Policy: Georgia and Advance Directive: Georgia policy. However, there was no evidence that this system was routinely monitored by the Administrator, to ensure that it was accurately and consistently implemented. Review of the facility policy which was in place for Cardiopulmonary Resuscitation (CPR), one-person policy revealed that the policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directive or in the absence of advance directives or a DNR order. However, there was no evidence that this system was routinely monitored by the administrator, to ensure that, in an emergency situation, nursing staff could response and implement the policy appropriately. Record review for Resident (R) A revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE] per a Nurse's Note dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula, the note documented that the resident returned to his bed then returned to the bathroom and again turned on the call light. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a Medication Administration Record (MAR) record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., Emergency Management Services (EMS) personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. A telephone interview with the Administrator, Regional Vice President (VP), and the DHS on [DATE] at 11:00 a.m., during review of the A[NAME] with the State Survey Agency (SSA) Regional Director, revealed that the Medical Director had not been involved in the development of the self-imposed IJ plan of action and that a full QAPI committee meeting had not taken place. Additionally, the facility had not reviewed the current Advanced Directive Policy and Procedures as part of the self-imposed IJ action nor had in-services included the CNAs, rather only the licensed nurses had been in-serviced. Therefore, the self-imposed IJ action plan did not remove the I[NAME] Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include physician's order, documentation on the Physician's Order Form (POF), documentation on the list in front of the MAR, appropriate signatures from two physicians if the resident is not competent, responsible party signature if the resident is not competent, documentation on the care plan and on the CNA guide. The Advance Directive facility checklist will be used to record the audit. New admissions will have their advance directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders it stopped. This may be a facility physician, if the CPR was started in error, or the emergency room physician once the ambulance personnel arrive and call the physician. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and and order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE], nor had a full QAPI meeting taken place prior to the survey entrance to investigate the complaint. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to ensuring the accuracy of Advanced Directives and the Administrator's oversight of this process: 1. The DHS and Senior Nurse Consultant completed an audit of all active resident records on [DATE] and [DATE] utilizing the Advance Directives facility checklist. 2. Review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) completed on [DATE]. Policy revision recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. The policy was revised and published on [DATE] to include removal of the above referenced section. 3. The Social Worker (SSD) was terminated on [DATE] for failing to ensure accuracy of DNR list per policy. 4. The Advance Directive Clinical system checklist will be updated upon each new admission or change in advance directive orders by the DHS, Unit Manager or Social Worker (SSD). 5. The Administrator will review the Advance Directive clinical checklist in the QAPI meetings monthly for three months and quarterly thereafter. 6. The Administrator was educated on [DATE] by the AVP on the Administrator job description and responsibilities. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of audit list dated [DATE] and [DATE] confirmed that all active residents medical record were audited utilizing the Advanced Directives facility check list. 2. A review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) was conducted on [DATE]. A policy revision was recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. Policy revision was completed by corporate office and published on [DATE] reflecting removal of the above referenced section. 3. Review of the personnel records for the SSD confirmed separation notice dated [DATE]. 4. A interview with the DHS on [DATE] at 1:45 p.m. and the Unit Manager, RN FF on [DATE] at 3:45 p.m. revealed the DHS provided evidence that new Physician's Orders and that new admission orders [REDACTED]. Review of the Advanced Directives Clinical system checklist was reviewed on [DATE]. 5. An interview and review of the Advanced Directive Checklist on [DATE] at 12:46 p.m. revealed the Administrator is responsible for review of the checklist and to present the findings to the QAPI meeting monthly for three months then quarterly thereafter. 6. Review of the description with acknowledgment page for the Administrator signed and dated [DATE]. An interview with the AVP on [DATE] at 12:46 p.m. confirmed that he had reviewed the Administrator's job description and responsibilities with the Administrator on [DATE]. An interview with the Administrator on [DATE] at 12:46 p.m. revealed that the DNR policy was reviewed and revised by an ad hoc QAPI committee which including the Medical Director. She confirmed that the Area Vice President (AVP) had reviewed and in-serviced the Administrator on her job description and duties. The Administrator will oversee the A[NAME] plan. She confirmed the SSD and that Licensed Practical Nurse (LPN) OO have been terminated. | 2020-09-01 |
| 2023 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 278 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. He eloped again on [DATE] with his remains found on [DATE]. The Sample size was six residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately a quarter of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified [MEDICAL CONDITION], generalized anxiety disorder, adjustment disorder, unspecified dementia, [MEDICAL CONDITION], and dementia with behavior disturbance. Review of R#1's Minimum Data Set (MDS) annual review dated [DATE] revealed under Section C - Cognition, that resident is severely cognitively impaired. Under Section [NAME] - Behaviors, R#1 is not coded for wandering behavior, but his previous MDS assessments from [DATE] through [DATE] were coded for wandering. Resident also had delusions, exhibited verbal behaviors ,[DATE] days of the review period and exhibited other behaviors ,[DATE] days of the review period. Under section G- Functional Status, the resident required supervision for most activities of daily living, but needed extensive assistance to dress and maintain personal hygiene. Review of 'Interdisciplinary Progress Notes' dated [DATE] recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: 'also, at 4:35 p.m. staff member alerted nurse that (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. Resident had no injuries noted to body, appeared to be in no distress. Resident showed nurse writer how he had gotten out. Apparently, while the heating and air service men were working on the unit they left the door open and resident walked outside. Resident stated, I'm sorry, I was just trying to get home'. Continuing review of the 'Interdisciplinary Progress Notes' related to the elopement reveals there was no follow-up documented or re-assessment recommended. Review of R#1's current 'Plan of Care' for wandering/elopement revealed it originated on [DATE] and had not been updated or revised related to the elopement on [DATE]. Problem 004, on page 4 of the plan of care reads as follows: Resident has the potential for leaving the facility grounds due to poor decision making skills. He requires supervision and redirection throughout the day. Under 'Goals', dated [DATE], it reads: Resident will not leave the facility grounds without an escort through next review. There are 4 'Interventions' listed to meet this goal, all dated [DATE], that read as follows: 1. Cue & Redirect as needed 2. Involve resident in activities as a diversion, encouraging resident to attend activities of preference. 3. Observe resident's location & redirect as needed 4. Notify MD (Medical Director) as needed. Under 'Start Date' for the 'Interventions' are two handwritten dates, [DATE] and [DATE], but no additional interventions or revisions are recorded. Interview on [DATE] at 11:10 a.m. with the DON who confirmed that the resident had previously eloped in (YEAR) under similar circumstances. She further states that the facility made a policy change requiring that the security codes on the doors be changed monthly after R#1's elopement in (YEAR). There was no follow-up investigation or tracking tool used to measure effectiveness of this intervention and no re-assessment of this resident or other residents at risk for elopement. Continuing interview with the DON revealed the facility had no formal assessment tool for elopement. The DON was not aware that the resident attempted to 'catch' doors before they closed, but was aware that he had entered other resident's rooms and was known to observe staff entering the code to open the secured doors and agrees that these should have been on the resident's care plan. The facility implemented the following actions to remove the Immediate Jeopardy 1. On [DATE] the Regional Nurse (RN), Director of Nursing (DON), Assistant Director of Nursing (DON) and one Resident Care Coordinator reassessed all patients to determine elopement risk using the elopement risk assessment tool. Fifteen out of eighty-one residents were identified as high risk. Care plans for these patients were reviewed and updates made as indicated by Resident Assessment Instrument (RAI) Coordinator, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. 2. On [DATE], the remaining care-plans that had been reviewed for elopement/wandering risk but were not high risk were reviewed for medium and low risk patients and were updated as indicated by RAI Coordinator, Restorative Nurse, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. 3. On [DATE], the Administrator and Director of Nursing educated the RAI Coordinator, Restorative Nurse, Assistant Director of Nursing, and two Resident Care coordinators on ensuring wandering risk, communication of any patient reviewing and revising patient care plans as patient's conditions change and their roles in the interdisciplinary team assessment and care planning process. 4. Education will be provided to licensed nurses on this process. There are currently nineteen on staff. This education will be provided by the Director of Nursing and will be completed by close of business on Friday, [DATE]. The education will begin at 4:00 p.m. and will end at 4:30 p.m. If all 19 licensed nurses do not participate, education will be provided to those who were unable to attend by Director of Nursing via telephone. Each nurse will be required to receive the education prior to providing patient care. 5. Newly hired nurses will be provided education on elopement risk assessment during orientation by the Director of Nursing or Assistant Director of Nursing. 6. Policy review was performed by the Vice President of Clinical Practice on [DATE]. Policy is being revised and will be implemented on [DATE] for center to perform elope risk assessments at least monthly due to patient population. 7. Patients will begin receiving elopement risk assessments at least monthly by licensed nurses with the baseline risk assessments being those performed on [DATE]. 8. All findings were entered into the QAPI program by the Administrator. This will continue to be reviewed by the Quality Assurance Performance Improvement (QAPI) team members during the monthly QAPI meetings until compliance is achieved and sustained. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Elopement Risk Assessment Tool was used for assessment of all residents resulting in 15 high risk residents identified. Elopement Risk Assessment Tool will be the new base-line going forward for assessment and re-admissions. 2. On [DATE] copies of the new care plans were reviewed for all residents in the high, medium, and low risk categories. All care plans had been updated as indicated by RAI Coordinator, Restorative Nurse, ADON, DON, two Resident Care Coordinators and Regional Nurse Consultant. Review of updated care plans reveals appropriate new interventions have been added. 3. On [DATE] and [DATE], the Administrator and Director of Nursing educated the RAI Coordinator, Restorative Nurse, Assistant Director of Nursing, and two Resident Care coordinators using a printed Power Point tool that expanded on the interventions used for wandering risk, communication, reviewing and revising patient care plans as patient's conditions change and their roles in the interdisciplinary team assessment and care planning process. Review of the training tool on [DATE] at 11:55 a.m., review of the signatures page, and interview with RAI Coordinator confirmed that the training had been done and the RAI coordinator was able to verbalize the training material. 4. All staff have been educated in person or by telephone by [DATE]. Interview with Licensed Practical Nurse (LPN) Charge Nurse RR who confirms that training on [DATE] and ,[DATE] /17 was completed on [DATE] between 2:30 p.m. and 3:00 p.m. Review of the training sheet and the staff records reveals that all staff have received the specified training either in person or by phone. 5. Interview on [DATE] at 2:40 p.m. revealed that the Director of Nursing or Assistant Director of Nursing have provided a copy of the new elopement risk assessment tool to be incorporated into the training packet for all new nurses. 6. Interview and review with the Vice President of Clinical Practice on [DATE] at 1:35 p.m. reveals that the policy is being revised and will be implemented on [DATE] for the entire center to perform elope risk assessments at least monthly due to the patient population. 7. Interview on [DATE] at 9:15 a.m. with Social Service Director (SSD) who confirms that high risk residents were assessed on [DATE] and will be assessed monthly, all other residents will be assessed quarterly, annually, as needed or based on significant change, and new or re-admissions will be assessed on admission. 8. Review of QAPI plan, tools initiated and staff interviews on [DATE] at 4:40 p.m. with DON, ADON and the RVP confirm this process as of [DATE]. | 2020-09-01 |
| 1254 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 678 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess the Advance Directive status and provide continued Cardiopulmonary Resuscitation (CPR) for one resident (A) and failed to ensure the Advance Directive status was accurately reflected on the physician's orders for two residents (#2 and #3), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. RA experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Do Not Resuscitate Policy: Georgia. The policy included that a written list of all residents who have DNR orders would be kept in the front of the current MAR book. The Social Worker (SSD) would be responsible for keeping the list updated. The facility also had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. 1. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a Physician's Order since at least [DATE] for oxygen to be administered continuously at two liters per minute via nasal cannula. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent nurse's note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. There was no evidence that an attempt was made to verify the accuracy of the DNR form maintained in the MAR book and Resident A's Advance Directive status, through a review of his clinical record, prior to the cessation of CPR. During interviews on [DATE] at 4:24 p.m. with Licensed Practical Nurse (LPN) OO and on [DATE] at 7:28 a.m. with LPN PP, both of whom were present and responded to the resident's change in condition on [DATE], both confirmed that they did not look for Advance Directive information in the resident's chart. In addition, there was no evidence that the DHS verified R A's Advance Directive status prior to pronouncing his death on [DATE] at 7:09 a.m. During an interview on [DATE] at 1:45 p.m., the DHS confirmed that she did not verify the resident's Advance Directive status prior to pronouncing his death on [DATE]. During an interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. Review of the State of Georgia, State Office of Vital Records, Pronouncement of Death dated time of death [DATE] at 7:09 a.m. and signed by the DHS. Review of the Georgia Death Certificate Worksheet-Medical Record form revealed the following cause of death, [MEDICAL CONDITION], Chronic [MEDICAL CONDITION] Fibrillation, and Chronic Systolic Heart Failure which was signed by the MD on [DATE]. 2. Resident #2 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form for Adult Patient/Resident With Decision -Making Capacity: Georgia form was signed by Resident #2 on [DATE] and by the physician on [DATE]. However, a review of the clinical record revealed that the Advance Directive status was inaccurately documented on the (MONTH) (YEAR) Physician order for [REDACTED]. 3. Resident #3 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form For Adult Patient/Resident Without Decision-Making Capability With Durable Healthcare Power of Attorney Only: Georgia was completed on [DATE]. However, a review of the clinical record revealed that the Advance Directive status was inaccurately documented on the (MONTH) (YEAR) POF's. The (MONTH) (YEAR) POF documented that the resident's Advance Directive status as Full Code instead of DNR. The (MONTH) (YEAR) POF's were accurate for the DNR status. A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include Physician's Order, documentation on the Physician's Order Form (POF), documentation on the list in front of the MAR, appropriate signatures from two physicians if the resident is not competent, responsible party signature if the resident is not competent, documentation on the care plan and on the CNA guide. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of advance directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders it stopped. This may be a facility physician, if the CPR was started in error, or the emergency room physician once the ambulance personnel arrive and call the physician. When looking to confirm an advance directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to Quality Assurance Performance Improvement (QAPI) monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to Advanced Directives: On [DATE] the Facility Administrator, Director of Health Services (DHS), Area Vice President (AVP), Senior Nurse Consultant (SNC) and Senior Vice President of Clinical Services (SVPCS) met via telephone conference for immediate QAPI interventions to the cited incident. The Medical Director was notified of the interventions via phone on [DATE] and concurred with initial self-imposed interventions as detailed in the below A[NAME]. DHS called MD to follow-up on [DATE] to provide additional interventions and plan progress. 1. A review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) was conducted on [DATE]. A policy revision was recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. Policy revision was completed by corporate office and published on [DATE] reflecting removal of the above referenced section. The new policy was reflected in education listed in #3 below. 2. The Social Worker (SSD) was terminated on [DATE] for failing to ensure accuracy of the DNR list per policy. 3. All licensed and certified staff were educated from [DATE] through [DATE] by the DHS and CCC to verify advance directive/code status via the resident's chart. Fourteen of 14 LPN's were educated as of [DATE] (100%), seven of eight RN's were educated as of [DATE] (87.5%). Twenty-nine of 34 active CNA's completed education as of [DATE] (85%). 4. All newly hired licensed and certified staff will be educated during orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA, or an as-needed work status will not work until this education is completed. 5. All licensed and certified nursing staff were educated from [DATE] through [DATE] to continue CPR (even if in error) until a physician orders it stopped, or the resident becomes responsive. Fourteen of 14 LPNS were educated as of [DATE] (100%), seven of eight RN's were educated as of [DATE] (87.5%), and 29 of 34 active CNA's completed education as of [DATE] (85%). 6. The facility DHS, Nurse Managers and/or Administrator will conduct mock code drills to ensure compliance weekly for four weeks and monthly for two months. Results will be communicated by the DHS at QAPI monthly meetings for three months. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of the facility policy titled Do Not Resuscitate Policy: Georgia by AVP and SVP of Clinical Services dated [DATE], revealed the section A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping the list updated had been removed. 2. Review of the personnel records for the SSD confirmed separation notice dated [DATE]. 3. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that on [DATE], [DATE] and [DATE] that 100% of the RNs, LPNs, and that 29 CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, change in condition, nursing runs the code, that once CPR is started then it cannot be stopped without a doctors order and that mock code procedure had been put into place. The facility provided evidence that four mock drills had been conducted by [DATE], with sign-in sheets and evaluation had been completed. The mock codes drills will continue. 4. An interview with the CCC on [DATE] at 1:20 p.m. confirmed that one new staff member had been hired on [DATE] and verified through sign-in sheets that the new staff person had been educated. The CCC confirmed that any new staff, or any staff, not already in-serviced, would be in-serviced on the new policy and procedure for checking the Advanced Directive Status, change in condition, and nursing runs a code and that once CPR is started it cannot be stopped without a doctor's order chart prior to working. 5. An interview with the CCC on [DATE] at 1:20 p.m. verified per review of the sign-in sheets and in-service records that licensed staff and certified staff were educated to continue CPR (even if in error) until they had MD (physician) orders to stop or if the resident becomes responsive. 6. Observation on [DATE] at 11:50 a.m. of a Code Blue being announced in a resident's room over the intercom. Observation of the mock drill in progress by the surveyor revealed that the DHS and Corporate Nurse Consultant were guiding the nurses and CNA's on roles which included: providing CPR and rescue breathing on CPR mannequin, role delegation, step by step instruction on use of AED (Automated External Defibrillator) use, continuation of CPR until mock EMS arrival to take over, notifying the MD, family and charting afterwards. The DHS made a point to clarify that licensed nurse oversees the code, should be in the room with the resident. The mock drill list was reviewed with staff. Staff present ran smoothly through the drill. Review of the Mock Code Drills education checkoff sheet revealed the following: date, time, number of participants (see sign in sheet), nurse in charge on scene, nurse assigned duties, crash cart present and AED utilized and reviewed, scribe assigned and writing, paged code, chart brought to room or reviewed for code status, 911 called, MD and RP called and documented in chart, crash cart restocked and sealed. Record review of Mock Drill form dated [DATE] and interview with the DHS on [DATE] at 1:45 p.m. confirmed the Mock Drills will be conducted weekly for four weeks then monthly for two months. The DHS confirmed that she will present the findings to the QAPI committee monthly. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. | 2020-09-01 |
| 3478 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 678 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess the Advance Directive status for one resident (#4) and failed to accurately document the Advance Directive status for one resident (#12) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on (MONTH) 29, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Advance Directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: The facility had an Advance Directives: Georgia policy. The policy statement included that the healthcare center recognizes the right of residents to control decisions related to their medical care. The policy procedure included that prior to, or upon admission, the resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directive Checklist will be completed. During an interview on [DATE] at 11:10 a.m., Nurse Consultant UUU stated that the facility went live with using an electronic clinical record system on [DATE] and that the staff was trained on the system as the different components came on line. The facility provided an agenda for the staff training for [DATE] through [DATE] and sign in sheets for the training. 1. R#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, progress notes documented the resident was status [REDACTED]. A Georgia Advance Directive for Healthcare form and DNR form, were signed by the resident's responsible party on [DATE]. The Georgia Advance Directive for Healthcare form documented that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The DNR form documented that the resident did not have a DNR order or Physician order [REDACTED]. R#4 experienced a change in condition on [DATE]. A nurse's note dated [DATE] at 5:22 a.m., documented that upon entering the resident's room, the resident was unresponsive to verbal and physical stimuli. The note also documented that they were unable to obtain a blood pressure, pulse, respirations or pulse oximetry, and her temperature was 90.3 degrees. The DHS was notified, and a message was left for the on-call physician. There was no evidence that emergency basic life support measures were immediately implemented. The subsequent nurse's note, approximately one hour later, on [DATE] at 6:25 p.m. documented that CPR was started. Further review of nurses' notes entries revealed that EMS personnel were onsite and took over CPR at 6:30 a.m. and continued emergency life support measures, but without success. EMS personnel received a physician's orders [REDACTED]. During an interview on [DATE] at 7:35 a.m., Licensed Practical Nurse (LPN) AA stated that, after finding the resident unresponsive and unable to obtain vital signs, she checked the resident's electronic chart. She stated that she thought she saw DNR on the Advance Directives section of the chart and notified the DHS. However, when she started the paperwork, she could not find DNR information and called the DHS again, who arrived shortly afterward and called 911 and began CPR. LPN AA stated that she would have started CPR immediately, if she had not thought she saw DNR on the electronic chart. During an interview on [DATE] at 4:30 p.m., the DHS confirmed that she received a call from LPN AA the morning of [DATE] regarding resident #4's passing and that the resident was a DNR. The DHS stated while enroute to the facility to pronounce the resident's death, she received another phone call from LPN AA notifying her of that she could not locate DNR information. The DHS stated she arrived shortly afterward, reviewed the chart, and in seeing no Advance Directive status specified, called 911 and initiated CPR. The DHS stated that Advance Directive/Code Status is verified in the electronic clinical record at the top of the computer screen, on the banner. If there is no Advance Directive/Code Status listed there, you assume the resident is a full code (not a DNR). She stated that there is no need to scroll down to the Advance Directive section of the chart because whatever is checked in that section will appear on the banner (at the top of the screen). During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. In response to the incident, she interviewed staff, called a Quality Assurance Plan Improvement (QAPI) meeting (on [DATE]), put a plan in place and began auditing residents' Advance Directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. [NAME] The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the facility's electronic clinical record system integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. B. The Administrator or designee would complete a daily audit tool to monitor Advance Directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting Advance Directive documentation. 2. Review of the Medical record revealed that R#12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#12 was to be a Do Not Resuscitate (DNR). However, review of the electronic medical record revealed there were no supporting documents to validate the resident's DNR status. Review of the Resident Progress Notes dated [DATE] at 3:00 p.m. revealed that at 2:40 p.m. the nurse was notified by a family member that the resident was unresponsive to all stimuli. The note further documented that the resident was assessed by two nurses and found to be without any vital signs. At 2:45 p.m. the funeral home was notified and was awaiting arrival of the funeral home personnel. The resident had an pronouncement of death by RN CC on [DATE] at 2:45 p.m. During an interview with Licensed Practical Nurse (LPN) BB on [DATE] at 11:35 a.m., she stated that the resident's daughter had reported to her the resident was not responding. She stated that she went and got Registered Nurse (RN) CC who got the crash cart and when they entered the room the resident's son told them the resident was a DNR. She stated when she checked the face sheet she saw where the resident was a DNR and they did not do Cardiopulmonary Resuscitation (CPR). During an interview with RN CC on [DATE] at 12:03 p.m., she stated that LPN BB came to her and said the resident was nonresponsive. She grabbed the crash cart while LPN BB got the electronic record to check the resident's code status. As they were entering the room, LPN BB stated the resident was a DNR. She also stated that as they were entering the resident's room, the son asked them what they were doing with the crash cart since his mother was a DNR. She stated she went in the room to assess the resident who did not have a pulse, no respirations, and her pupils were fixed and dilated. She stated that she was the nurse who pronounced the resident's death. During an interview with Nurse Consultant UUU on [DATE] at 10:30 a.m., she provided a copy of the resident's Advanced Health Care Directive which was faxed from the hospital. However, the fax date was [DATE] at 9:22 a.m. She stated that the facility did not have a copy of the Advanced Directive until after surveyor inquiry on [DATE], 25 days after the resident's admitted . She also stated that the family told the facility they would bring a copy of the Advanced Directive on the following Monday, the seventh. She stated the resident should have been a full code until they had a copy of the Advanced Directive. The facility implemented the following actions to remove the Immediate Jeopardy: Personnel will provide basic life support including CPR to a Resident requiring such emergency care before the arrival of emergency medical personnel and subject to related physicians order and Residents Advanced Directive. Root Cause Analysis Nursing staff did not provide CPR on Resident #4 and Resident #12. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) Clinical Competency Coordinator or designee will ensure all staff know how to confirm the Residents Advanced Directives. 2) All staff were educated on [DATE]. As of [DATE] we trained ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81%), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%) by the Director of Health Services and the Clinical Competency Coordinator to verify code status via Resident chart. Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained on during orientation on basic life support including CPR. Director of Health Services and Administrator completed an audit with all staff on [DATE] to ensure the staff know how to confirm the Residents medical record. 3) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 4) Clinical Competency Coordinator or Director of Health Services will randomly audit 10% of all staff weekly to ensure staff knows how to confirm residents code status by return demonstration. Administrator or designee will audit Advanced Directives in the electronic medical record daily x2 months or until substantial compliance is complete. 5) Findings will be communicated by the Director of Health Services at Quality Assurance Performance Improvement monthly x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. An interview with Registered Nurse CC (Clinical Care Coordinator) on [DATE] at 12:33 p.m. revealed that staff were in-serviced on [DATE] and any remaining staff were in-serviced before starting their next shift at the facility. 2. The following interviews revealed that all of the staff were able to describe the in-service training for the Advance Directives, Code Status and care planning for Code Status. They stated they have had three to four classes on the topics and then a refresher was done every day where the management would come ask them questions and some had to do a return demonstration to make sure they understood. They were able to describe where to find the resident's Code Status, the banner and in resident electronic documents. They also stated if there was no Code Status on the banner or the documents that the resident would be full code and they would have to start CPR. They stated the resident would be a full code until the proper documents were provided. They also discussed the care plans, where the Code Status would also be included. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 3. The Advanced Directive Policy was reviewed and signed by the Administrator on [DATE] and verified with an interview on [DATE] at 2:32 p.m. with the Administrator. 4. Verified via interview [DATE] at 12:33 p.m. with CCC CC, interview [DATE] at 1:15 p.m. with the DHS and review of audit documentation and completed Advance Directive checklists. Also verified via interview [DATE] at 2:32 p.m. with the Administrator who stated she had actually been auditing the lists twice daily. 5. Verified via interview [DATE] at 1:15 p.m. with the DHS confirming that the audit findings will be communicated at the QAPI meetings monthly. | 2020-09-01 |
| 3476 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 655 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to develop a baseline care plan for the advance directive status for one resident (#4) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on (MONTH) 29, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Advance Directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: R#4 was admitted to the facility on [DATE]. A review of the Georgia Advance Directive for Healthcare and DNR forms, signed by the resident's responsible party on [DATE] revealed that the resident had not executed an Advance Directive and did not have a DNR order. A base line care plan was developed that included problems with dates of [DATE] and [DATE] and [DATE]. However, the care plan did not include the resident's Advance Directive status. During an interview on [DATE] at 4:30 p.m., the DHS stated that the Advance Directive/Code Status is verified in the electronic clinical record at the top of the computer screen, on the banner. If there is no Advance Directive/Code Status listed there, you assume the resident is a full code (not a DNR). She stated that there is no need to scroll down to the Advance Directive section of the chart because whatever is checked in that section will appear on the banner (at the top of the screen). The DHS confirmed that the Advanced Directive status was not included on the Baseline Care Plan for R#4 which should have been completed by the admitting nurse and was not completed. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy: Each Resident must have a Resident centered baseline care plan, followed by a comprehensive care plan developed following completion of the Minimum Data Set and Care Area assessment portion of the comprehensive assessment according to the Resident Assessment Instrument manual and the Resident's choice. Root Cause Analysis The facility failed to develop a Baseline Care Plan to reflect current code status for Resident #4. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) MDS Nurses, Senior Nurse Consultant Completed an audit of all resident care plans to ensure correct code status on care plan on [DATE]. MDS Nurse completed an audit of resident care plans on [DATE] for residents with DNR and Full Code Advance Directives. 2) Resident #4 and Resident #12's Care Plan was updated to reflect their Advanced Directives. Director of Health Services and Administrator completed an audit of all active resident records on [DATE] to ensure the residents care plans were accurate. There were no other Residents identified during the audit with inaccurate Care Plans. 3) Care Plan Coordinator/MDS Nurse educated by Senior Nurse Consultant on [DATE] to initiate Advanced Directives/Do Not Resuscitate/Full Code Care Plan once an order is received. As of [DATE] we have trained ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81%), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%). Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained during orientation on baseline care plans for an Advanced Directive. The Director of Health Services and/or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and ensuring any Do Not Resuscitate or Full Code orders are carried through to the care plan. This process will be documented on the Advance Directives Checklist by the Director of Health Services or Unit Manager. 4) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 5) Findings will be reported in Quality Assurance Performance Improvement Committee by the Director of Health Services or Unit manager x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. An interview and record review with the Minimum Data Set (MDS) Coordinator on [DATE] at 12:45 p.m. revealed that chart audits have been completed daily for Advance Directives and corresponding care plans from [DATE] through [DATE]. She further stated that as of [DATE] the audits include that the correct Code Status and that the corresponding paper work is included in the resident's record. 2. Review and verification of the facility's audit documents, care plans and Advance Directive documentation for residents with a DNR is specified in the resident's chart. 3. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to developing a Base Line Care Plan for Code Status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the development of Base Line Care Plans for Code Status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director of Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to developing a Base Line Care Plan for Code Status and their role in the process: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 4. Per interview and review of the Care Plan Policy, confirmed that the facility Baseline Care Plan Policy was reviewed and approved on [DATE] with input from the Medical Director and Nursing. The policy was signed by the Administrator on [DATE]. 5. Record review and interviews with the Administrator and DHS on [DATE] at 1:15 p.m. and 2:32 p.m. which confirmed that a QA meeting was held on [DATE] after the death of R#4 to put a plan into place which included an audit of all resident's records for Advanced Directive Status. Additionally, a QA meeting was held on [DATE], which included the Medical Director (via telephone) to update the plan to address the Advance Directive error and review the affected policies of the facility, which included Base Line and Comprehensive Care Plans. | 2020-09-01 |
| 1252 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 656 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to develop a care plan for the advance directive status for four residents (A, #2, #3, and #15) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: 1. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. However, the resident's Advance Directive status was not included in his care plan. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. The DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. nurse's note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an advance directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. However, there was no evidence in the clinical record that a care plan was developed to include the resident's Advance Directive status on admission or during the care plan updated on [DATE]. During an interview on [DATE] at 11:30 a.m., the Minimum Data Set (MDS) Coordinator stated that prior to [DATE] that only the DNR Advance Directive Status had been added to residents' care plans but now all residents have their advance directive status (Full code or DNR) included in the care plan. She confirmed that R A care plan did not include the Advance Directive Status. Cross refer to F678 2. R #2 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form for Adult Patient/Resident With Decision -Making Capacity: Georgia form was signed by resident #2 on [DATE] and by the physician on [DATE]. However, there was no evidence in the clinical record that a care plan was developed to include the resident's initial Advance Directive status on admission or new advance directive status of DNR in (MONTH) (YEAR). Cross refer to F678 3. R #3 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form For Adult Patient/Resident Without Decision-Making Capability With Durable Healthcare Power of Attorney Only: Georgia was completed on [DATE]. However, there was no evidence in the clinical record that a care plan was developed to include the resident's initial advance directive status or new advance directive of DNR in (MONTH) (YEAR). Cross refer to F678 4. R#15 was admitted to the facility on [DATE]. A Physician order [REDACTED]. A review of the clinical record revealed no evidence that the resident's DNR status had been included in the care plan. Cross Refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of advance directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for advance directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. The facility conducted an Advance Directive audit on [DATE] of all residents' Advance Directives information. The audit included reviewing the care plan for the inclusion of DNR status. A review of the audit tool dated [DATE] revealed that R#15 was identified as not having a care plan in place for the DNR status. However, there was no evidence in the clinical record that a care plan was developed to address R#15's DNR status, until after surveyor inquiry on [DATE]. During an interview on [DATE] at 12:16 p.m., the DHS confirmed that a care plan for R#15's Advance Directive status had not been developed until after surveyor inquiry on [DATE]. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy related to Advanced Directive care plans: 1. MDS Nurse, DHS and Senior Nurse Consultant Completed an audit of all resident care plans to ensure correct code status on care plan on [DATE]. MDS Nurse completed an audit of resident care plans on [DATE] for residents with DNR Advance Directives. 2. Any care plans identified were corrected and placed on the chart. Two (2) Residents with no care plan for DNR Advanced Directive care plan. Those care plans were printed and placed on the chart on [DATE]. All Active residents will have a care plan indicating Advanced Directive/Code Status. (sic) 3. Care Plan Coordinator/MDS Nurse educated by CCC on [DATE] to initiate Advanced Directives/DNR Care Plan once an order is received. 4. The DHS and or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and assuring any DNR orders are carried through to the care plan. This process will be documented on the Advance Directives Checklist by the DHS or Unit Manager. 5. Findings will be reported in QAPI by the DHS or Unit manager x3 months, The State Survey Agency (SSA) validated the corrective actions taken by the facility as of [DATE] as follows: 1. An interview with the DHS on [DATE] at 1:45 p.m. and the MDS Coordinator at revealed they had audited all resident care plans to ensure correct code status. Record review of audit list/spread for all resident's care plan was reviewed and completed. 2. Review of the resident's care plans were reviewed to ensure the correct Advanced Directives were in place utilizing audit/spread sheet. An interview with the MDS Coordinator on [DATE] at 11:30 a.m. verified the process of audit has been completed. 3. Record review of in-service sign in sheet verified the MDS Coordinator had been in-serviced on developing an Advanced Directive care plan once a physician's orders [REDACTED]. 4. A interview with the DHS on [DATE] at 1:45 p.m. and the Unit Manager, RN FF on [DATE] at 3:45 p.m. revealed the DHS provided evidence that new physician's orders [REDACTED]. This process was confirmed by the RN FF. 5. Review of the QAPI process revealed that the Audit findings will be presented to the QAPI meeting monthly by either the DHS or Unit Manager, RN FF. This process was confirmed by interview with the DHS and Unit Manager, RN FF on the dates and times listed in #4. An interview on [DATE] at 1:45 p.m. with the DHS revealed that she had participated in in-services related to Advance Directives and having the correct information on each resident's care plan and updating as changes are made by residents or the responsible party. She is overseeing that the MDS Coordinator has reviewed all care plans against the Advance Directives for each resident and that any changes to the Advance Directive is updated timely. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the MDS Coordinator revealed they had all participated in in-services regarding care planning of Advanced Directives and were knowledgeable of the process. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed they had participated in in-services related to care plans for Advanced Directives. | 2020-09-01 |
| 2872 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2018-07-13 | 600 | D | 1 | 0 | O6WT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure one resident (R) (#2) was protected from sexual abuse of 3 sampled residents. The facility census was 68 residents. Findings include: Review of R#1's Annual Minimum Data Set ((MDS) dated [DATE] revealed his Brief Interview for Mental Status (BIMS) of 05 indicating that he was cognitively impaired. A quarterly MDS assessment dated [DATE] revealed R#1's BIMS 04. Review of the current diagnosis's listing for R#1 reveals he has unspecified [MEDICAL CONDITION] and cognitive communication deficit. Review of R#2's quarterly MDS dated [DATE] revealed a BIMS score providing cognitive status was not able to be performed. An annual MDS dated [DATE] revealed the BIMS score was again unable to be assessed. Review of the current diagnosis's listing for R#2 reveals he has an unspecified lack of expected normal physiological development in childhood and a cognitive communication deficit. Review of a nursing note dated 4/3/2018 at 1:30 p.m. by a Licensed Practical Nurse (LPN) revealed it was brought to her attention that R#1 was making sexual advances to workers in the facility. She explained to R#1 that is was inappropriate to talk and approach workers that way. Review of the Social Service Director (SSD) notes dated 4/11/2018 at 10:10 a.m. revealed the SSD and administrator asked R#1 if he made any inappropriate, sexual comments to anyone, and he said no. Administrator informed resident that it has been reported that he has made inappropriate, sexual comments to others and that behavior was not acceptable and would not be tolerated in this facility. R#1 again, denied behaviors. Administrator asked R#1 did he understand what she said regarding behaviors. R#1 stated yes mam, said bye, and walked away. Review of a nursing note dated 6/30/2018 at 4:00 a.m. revealed a Certified Nursing Assistant (C.N.A) informed an LPN that she walked in on R#1 in the room with R#2, and that she observed R#1 doing inappropriate acts on R#2. R#2 was assessed and his genital area had some redness. R#2 was monitored throughout the night until next shift arrived. Review of a nursing note dated 6/30/2018 at 7:02 (LATE ENTRY) (created date 7/2/18 16:21:21) written by the Director of Nursing (DON) revealed: This writer was notified by the on-call nurse, Registered Nurse (RN AA) that she received a call from facility stating that R#2, who is cognitively impaired/incompetent and unable to make decisions for himself was discovered to have another resident in his room engaging in inappropriate acts upon his person which were of a sexual nature. Interview on 7/5/18 at 2:20 pm with the Administrator revealed the police were called because the incident between the two residents was sexual where one could not consent. R#1 went into R#2's room. The roommate of R#2 reported to the Administrator that he awoke to see feet under the privacy curtain and called for a nurse. When the CNA arrived R#1 was shirtless and performing oral sex on R#2. The CNA asked R#1 What are you doing? Record review of EMS report dated 6/30/18 at 8:43 a.m. revealed the following documentation: Nursing Home called EMS to Interview on 7/5/18 at 6:06 p.m. with CNA BB revealed that R#1 wanted me to cut his fingernails, I was charting when R#1 came in the room and closed the door, he told me I like you, I like men. I asked him not to say that to me, and I reported it to the social worker. I don't recall what day it was. Afterwards he asked me to come sit with him and talk with him when he would be in the front lobby, but I kept my distance. Interview on 7/5/18 at 6:55 p.m. with the SSD revealed that CNA BB came to her and reported R#1 had walked up to him and asked for his phone number or something like that. CNA BB stated he told R#1 that was inappropriate. The SSD continued by stating R W came to her and told her that R#1 said he liked men, she asked R W was he afraid and she asked R W if R#1 had approached him in anyway, R W said no, but I just felt uncomfortable because I don't go that way. Interview on 7/5/18 at 8:09 p.m. with RN CC revealed that she was called around 6:56 a.m. the morning on 6/30/18 and it was reported to her that inappropriate sexual behavior between R#1 and R#2 had occurred. RN CC asked if someone saw it, the reporter said yes, RN CC said, you mean they saw his head going up and down on the victim's penis, they reported yes. Review of the Emergency Medical Report (EMS) dated 6/30/18 revealed they were notified by the facility at 8:43 a.m. for resident on resident sexual assault. An ambulance was sent to the facility and EMS contacted law enforcement. R#2 was transferred from the facility at 9:34 a.m. Law enforcement were also at the facility. Review of the Hospital records revealed on 6/30/2018 at 9:43 a.m. R#2 was examined by a Physician for sexual assault with a Recommendation to follow with MD on test results. Facility Policy Titled Abuse Prevention Policy and Procedure revision date of 4/19/18 revealed the purpose of this written Resident Abuse, and Misappropriation Prevention Program (RANMP) is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked could lead to abuse. The scope of the program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents, consultants, volunteers and staff of other agencies serving the individua, family members, legal guardians friends, or other individuals. | 2020-09-01 |
| 2688 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2019-11-07 | 689 | D | 1 | 0 | 1NRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that an accident, that occurred during a transfer and resulted in injury, was reported timely to prevent a delay in care for one of three residents (R#1) reviewed for accidents. Findings include: Resident (R) #1 had [DIAGNOSES REDACTED]. A care plan, dated 5/5/19, documented that R#1 was bed and chair bound and required physical assistance with bed mobility, transfers and locomotion. The care plan also included that a Geri-chair was utilized for comfort and positioning. A review of the clinical record revealed that a change in condition was identified on 7/29/19. An untimed 7/29/19 nurse's note documented that R#1's family thought the resident had a sprained left lower extremity. The Physician was notified, and orders were received to obtain x-rays of the bilateral lower extremities due to swelling, to rule out fracture. A review of the x-ray results revealed fractures to the left lateral cortex of the fibula and anterior cortex of the distal tibia. A walker boot was ordered applied to the left lower extremity. The resident's transfer status was also changed to be completed via a mechanical lift. Record review revealed a Physician order [REDACTED]. Review of a Radiology report dated 7/29/19 documented: a subtle medial malleolus fracture is suspected. Review of a Radiology report dated 7/30/19 documented: Non displaced [MEDICAL CONDITION] cortex of the fibula, questionable [MEDICAL CONDITION] cortex of the distal tibia. The facility initiated an investigation into the cause of the left lower extremity fractures. A subsequent 7/29/19 7:45 a.m. nurses note, completed by the Director of Nursing (DON), documented: she was made aware of the origin of the injury by a staff member on 7/29/19. On the Thursday prior to 7/29/19 (which would have been 7/25/19), when the resident was being transferred from the bed to the Geri-chair, her foot had become lodged between the bottom of the chair. Record review revealed a handwritten statement signed by CNA AA that documented the following: I CNA AA was caring for R#1 after preparing her clothes and under garments I began to transfer R#1 from the bed to the Geri-chair. While transferring R#1 to the Geri-chair her foot had gotten caught between the bottom part of the chair that folds. (sic) Record review revealed that R#1 had an order in place since 10/5/18 for two 325 milligram (mg) [MEDICATION NAME] tablets every six hours as needed for pain and an order in place since 10/8/18 for [MEDICATION NAME] 50 mg every six hours as needed for pain. However, review of the (MONTH) 2019 Medication Administration Record [REDACTED]. After the incident on 7/25/19 review of the (MONTH) 2019 MAR indicated [REDACTED]. During interviews on 11/7/19 at 12:45 p.m. and 3:50 p.m., the DON stated that R#1 was being transferred correctly by Certified Nursing Assistant (CNA) AA on 7/25/19 when her foot was caught under the Geri-chair. The DON stated that CNA AA did not report the incident of the resident's left foot getting caught under the chair on 7/25/19, when the incident occurred. The DON confirmed that CNA AA should have reported the incident on 7/25/19. | 2020-09-01 |
| 3480 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 760 | D | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that one resident (#11) from free from medication errors from a total sample of 30 residents. Findings include: Resident #11 was admitted to the facility on [DATE]. A review of the admission orders [REDACTED]. One drop of [MEDICATION NAME] 0.25% opthalmic solution was ordered to be administered twice daily to both eyes. One drop of [MEDICATION NAME] 0.01% opthalmic solution was ordered to be administered daily, at bedtime. A review of the clinical record, including the Medication Administration Record [REDACTED]. In addition, the 9:00 p.m. doses of [MEDICATION NAME] were not administered as ordered on [DATE] and 11/25/18, with documentation that the medication was unavailable. During an interview on 1/31/19 at 12:05 p.m. Licensed Practical Nurse (LPN) FF stated that when medications arrive from the pharmacy, they come to the nursing station and the nurses sign for them and add them to the medication carts. She also stated that if she documented the medications were not available, then that meant she did not have the medications to give. If she had them, she would have administered the medications as ordered. However, during an interview on 1/31/19 at 11:23 a.m., Pharmacist EE stated that the eye medications were filled on 11/24/18 and delivered to the facility that same day, around 5:00 p.m. | 2020-09-01 |
| 3323 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2018-07-25 | 656 | D | 1 | 0 | 75FB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that pressure ulcer treatment was provided as care planned for one resident (A) from a total sample of eight residents. Findings include: Resident (R) A was admitted to the facility on [DATE] with a stage IV pressure ulcer to the sacrum. There was a care plan problem in place, since 1/8/18, to address the pressure ulcer. The care plan included an intervention for licensed nursing staff to administer treatments as ordered. There was a physician's orders [REDACTED]. However, a review of the clinical record, including the Treatment Administration Record, revealed no evidence that the pressure ulcer treatment had been provided, as care planned, for three days in (MONTH) (5/5, 5/6 and 5/20/18), six days in (MONTH) (6/2, 6/3, 610, 6/16, 6/17 and 6/23/18), and one day in (MONTH) (7/15/18). During an interview on 7/24/18 at 12:10 p.m. Resident (R) A stated that his pressure ulcer treatment does not always get changed on the weekends. He stated that the facility did not have a wound treatment nurse on the weekends so the nurses had to decide on who was going to do treatments, and then it still did not get done. Interviews on 7/24/18 at 10:45 a.m. and 2:40 p.m. with the wound treatment Licensed Practical Nurse (LPN) stated that she provided wound treatments during the week (Monday through Friday) and the Registered Nurse (RN) supervisor provided wound treatments on the weekends. She also stated that she had noticed at times that treatments were not completed as ordered over the weekends. An interview on 7/24/18 at 3:38 p.m., with the Registered Nurse (RN) weekend supervisor AA stated that she was supposed to provide wound treatments, as ordered, and did so, if she was only supervising. However, she stated that she was unable to if she was also pulled to administer medications. She stated that if she was pulled to administer medications, she would also try and provide treatments to those residents assigned to her, but always had one or two that did not get completed. Cross reference to F686 | 2020-09-01 |
| 3324 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2018-07-25 | 686 | E | 1 | 0 | 75FB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that pressure ulcer treatment was provided as ordered for three residents (A, #2 and #3) from a total sample of eight residents. Findings include: During interviews on 7/24/18 at 10:45 a.m. and 2:40 p.m. the wound treatment Licensed Practical Nurse (LPN) stated that she provided wound treatments during the week (Monday through Friday) and the Registered Nurse (RN) supervisor provided wound treatments on the weekends. She also stated that she had noticed at times that treatments were not completed as ordered over the weekends. During an interview on 7/24/18 at 3:38 p.m., RN weekend supervisor AA stated that she was supposed to provide wound treatments, as ordered, and did so, if she was only supervising. However, she stated that she was unable to if she was also pulled to administer medications. She stated that if she was pulled to administer medications, she would also try and provide treatments to those residents assigned to her, but always had one or two that did not get completed. 1. Record review revealed that resident (R) A was admitted to the facility on [DATE] with a stage IV pressure ulcer to the sacrum. There was a care plan problem in place, since 1/8/18, to address the pressure ulcer that included an intervention for licensed nursing staff to administer treatments as ordered. The current physician ordered pressure ulcer treatment, since 5/11/18, was for licensed nursing staff to cleanse the pressure ulcer to the sacrum with normal saline or wound cleanser, apply Hydrogel, cover with an Alginate wound dressing and cover with a dry dressing daily and as needed. However, a review of the clinical record revealed no evidence that the pressure ulcer treatment had been provided, as ordered, for one weekend day in (MONTH) (5/20/18), six days in (MONTH) (6/2, 6/3, 610, 6/16, 6/17 and 6/23/18), and one day in (MONTH) (7/15/18). During an interview on 7/24/18 at 12:10 p.m. Resident (R) A stated that his pressure ulcer treatment did not always get changed on the weekends. He stated that the facility did not have a wound treatment nurse on the weekends so the nurses had to decide on who was going to do treatments, and then it still did not get done. Observation of wound care on 7/24/18 at 4:05 p.m. with the Treatment nurse revealed the resident had a small open pinpoint sized circular pressure ulcer to the sacrum. The wound was surrounded by healed, pink scar tissue indicated the wound was previously very large and has healed unevenly. The wound treatment was completed as ordered with no concerns. Review of the weekly skin assessment and measurements revealed the pressure ulcer was improving. 2. R #2 had a stage two pressure ulcer to the left ankle since at least 11/30/17. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed a physician's orders [REDACTED]. However, there was no evidence in the clinical record that the treatment was provided as ordered on four weekend days in (MONTH) (6/2/18, 6/3/18, 6/9/18 and 6/10/18). On 6/15/18 the treatment order to the left ankle was changed to cleanse the left outer ankle with normal saline, wound cleanser or sterile water, pat dry with gauze, apply Fibrocal or equivalent collagen and cover with bordered gauze or dry Kerlix and secure with tape once daily. However, there was no evidence the treatment was provided as ordered on weekend days 6/16, 6/17, 6/23, 7/15, 7/21 and 7/22/18. The resident refused for the surveyor to observe wound care. Review of the weekly wound assessment and measurements revealed the resident has had the pressure ulcer left ankle since (YEAR). The wound will improve then decline and improve again. Currently the wound is a Stage II PS measuring 2 centimeters (cm) by 1.5 cm by 0.1 cm in deep. Review of the right ankle weekly assessment and measurements revealed the would had resolved on 5/25/18. 3. R#3 had a stage two pressure ulcer to the sacrum since 6/11/18. The current physician's orders [REDACTED]. However, a review of the clinical record revealed no evidence that the pressure ulcer (PS) treatment had been provided as ordered for three weekend days in (MONTH) (6/16, 6/17, and 6/23/18) and three weekend days in (MONTH) (7/15, 7/21 and 7/22/18). A review of the (MONTH) (YEAR) TAR revealed a physician's orders [REDACTED]. However, there was no evidence in the clinical record that the treatment was provided as ordered on 6/16, 6/17 and 6/23/18. The pressure ulcer to the left heel healed on 6/25/18. The treatment order was changed to cleanse the right heel with normal saline or wound cleanser, pat dry with gauze, apply Sureprep or equivalent skin barrier wipe, dry dressing, and wrap with Kerlix and secure with tape daily. However, the were no evidence in the clinical record that the treatment was provided as ordered on 7/15, 7/21 and 7/22/18. Observation on 7/24/18 at 2:45 p.m. of the resident's PS treatment with the treatment nurse revealed the resident has an open PS to the sacrum. The wound bed was beefy red, had no signs of infection, was clean and odor free. The would measured 2.4 cm by 4.0 cm. The treatment nurse stated the resident was on Hospice services and had developed a pressure ulcer to the left heel. Review of the weekly skin assessments and measurements revealed the wounds were improving and decreasing in size. During an interview on 7/25/18 at 1:34 p.m., LPN BB confirmed that she was assigned to resident A and #3 on 6/16/18 and 6/17/18 but did not remember if she provided a wound treatment or not. She stated that she does not normally provide wound treatments, including on the weekends, and had not been trained to provide wound treatments. She further stated that the nurse supervisor provided wound treatments on the weekends. When the supervisor was also assigned to administer medications, she did not know who provided wound treatments because she did not have time to administer medications and provide wound treatments to the residents she was assigned. She also stated that she had not been instructed by the nurse supervisor to provide wound treatments, if the supervisor was also administering medications. LPN BB stated that she had changed resident A's wound treatment before, when it has been soiled, but not routinely. During an interview on 7/25/18 at 1:50 p.m. LPN CC confirmed that she did not provide a wound treatment for [REDACTED]. She stated that when she works on the weekends she had never been instructed to provide wound treatments for her assigned residents, unless a dressing came off or was soiled. She stated that the RN supervisor would provide the wound treatments on the weekends. LPN CC also stated that when the RN supervisor also had to administer medications, she, LPN CC had not been instructed to provide wound treatments to the residents she was also assigned to administer medications to. | 2020-09-01 |
| 2974 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 688 | D | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that restorative nursing services were consistently provided for one of four residents (B) reviewed for restorative nursing. Findings include: The facility had a Lippincott Procedure for a Restorative Nursing Program. The procedure noted that it was the policy of the facility to provide restorative nursing which focuses on achieving and maintaining optimal physical, mental and psychosocial functioning of the resident. The restorative nursing program is under the supervision of a licensed nurse and provided by restorative nursing assistants or certified nursing assistants or any other qualified staff. The procedure also documented if it is determined that the resident would benefit from a Restorative Nursing Program, the nurse should arrange for such a minimum of six days a week, unless otherwise noted. During an interview on 6/24/19 at 12:35 p.m., the Assistant Director of Health Services (ADHS) stated that she oversaw the restorative program and restorative certified nursing assistant (CNA) BBB provided the restorative nursing services. The ADHS also stated that restorative services are usually set up to be provided three to five times per week or as tolerated. She added that currently restorative CNA BBB had been out of the facility, since last week, on leave, and that a list of all residents who received restorative nursing services would be given to the CNA's assigned to the residents that day (6/24/19). Resident (R) B had [DIAGNOSES REDACTED]. She received skilled physical therapy services from 2/19/19 through 4/30/19 and was discharged to a Restorative Nursing Program on 5/1/19. Care plan problems were developed on 4/30/19 for requiring restorative assistance to maintain goals and for being at an increased risk for falls with interventions to complete passive range of motion (PROM) exercises and ambulate as able with a bariatric walker for 15 to 80 feet, with staff to follow close behind with a wheelchair. A review of the quarterly Minimum Data Set (MDS) assessment, dated 5/18/19, revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS assessment also documented that the resident was provided with extensive assistance from staff for transfers and supervision and set up assistance for ambulation. The Restorative Therapy Referral form, with an effective date of 5/1/19, included the approaches of 15 to 30 repetitions of therapeutic exercises to the bilateral lower extremities and ambulation with a bariatric walker for 15 to 80 feet as able. The goal of the program was to maintain range of motion and strength to the bilateral lower extremities and maintain ambulation. A review of the Restorative Log, Restorative I CNA Role, Restorative II CNA Role, and Restorative Nursing Flow Record forms from 5/1/19 through 7/1/19 revealed that range of motion services were provided 21 times in May, only six times in (MONTH) and once in July. Restorative ambulation services were provided 21 times in (MONTH) and only four times in June. There was no additional evidence that restorative services were consistently provided, as care planned after (MONTH) 2019. Although restorative documentation indicated that restorative services were being provided, during an interview on 6/24/19 at 10:24 a.m. and 6/26/19 at 3:20 p.m., RB stated that she had only been assisted by nursing staff to walk one time, since being discharged from physical therapy (4/30/19) and being placed on restorative nursing services. She further stated that she performed range of motion exercises herself, like physical therapist (PT) CCC showed her. During an interview on 6/24/19 at 12:20 p.m., PT CCC indicated that she did not think RB was receiving restorative nursing services. She had observed the resident ambulating with restorative only once, maybe twice. She stated that she did not feel like it was being provided based on what she was told by RB, who would ask her repeatedly, where restorative nursing staff was, and when restorative nursing staff was coming to ambulate with her. PT CCC did state that she, herself, was not at the facility all the time because she went to other buildings also. However, she thought that if restorative nursing services were being provided, RB would not have repeatedly asked her about it. PT CCC added that she used to go by the resident's room almost daily, going down her hall, and RB would call out to her, but she had not been down that hall and talked to her as much in the past month. PT CCC stated that she could not remember the last time that the resident complained to her about not getting walked with restorative. PT CCC stated that she had brought up her concerns to management in the past, and they had attempted to resolve the issue several times. PT CCC stated that RB was safe to ambulate but needed supervision to follow her with a wheelchair, obtain her walker for her, and manage her oxygen. During an interview on 7/3/19 at 10:30 a.m., the Director of Health Services (DHS) stated that she had not received any complaints regarding RB not being provided with restorative services and had observed her ambulating with three to four staff members once the previous week or two. | 2020-09-01 |
| 4405 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 520 | J | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to resident-to-resident abuse and use of [MEDICAL CONDITION] medications. The facility's failure to maintain an effective QA program that implemented a plan to safeguard residents from further physical abuse by R#39 was determined to be likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/8/16 and determined to first exist on 10/23/16, when R#39 first threatened R#56 with harm using a wire clothes hanger. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 12/8/16 at 2:55 p.m. An acceptable Allegation of Compliance (AoC) was received on 12/10/16 and the surveyors validated the Immediate Jeopardy was removed on 12/10/16 as alleged. The deficient practice remained at an F (widespread potential for more than minimal harm) scope and severity related to additional findings of non-compliance and Substandard Quality of Care. Findings include: During the annual recertification survey and complaints investigation from 12/5/16 to 12/10/16, the facility was found out of compliance with regulatory requirements regarding prevention of resident-to-resident abuse and use of [MEDICAL CONDITION] medications. Cross-reference F223: Physical Abuse. The facility failed to ensure that R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm. R#39 threatened R#56 with harm from a wire clothes hanger on 10/23/16. On 12/5/16, R#39 was observed hitting R#56 with a wire clothes hanger. The facility responded with an intervention to remove all wire clothes hangers from R#39's possession. On 12/8/16, a wire clothes hanger was observed in R#39's room. The nursing staff assigned to work with R#39 were unaware of the intervention to remove wire clothes hangers from his possession. Cross-reference F226: Abuse Policies and Procedures. The facility did not ensure R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm and failed to conduct a criminal background check for one of two active nurse managers reviewed. Cross-reference F280: Care Plan Revision. R#39's care plan was not revised to reflect an incident of threatening another resident; R#81's care plan was not revised to reflect the resident's positioning needs; R44's care plan was not updated with the development of a new pressure ulcer; R27's care plan was not revised to reflect the resident's current needs for help with activities of daily living; R#83, and R#22's care plans were not updated with non-pharmacological interventions to address behavioral symptoms; and R#51's care plan was not reviewed quarterly as required. Cross-reference F329: Unnecessary Medications. The facility failed to ensure the drug regimen was free of unnecessary drugs including the use of [MEDICAL CONDITION] medications, including PRN (as needed) injections of medications and multiple medications from the same drug class for R#88, R#40, and R#56. Cross-reference F428: Medication Regimen Review. The facility failed to ensure the drug regimen recommendations from the pharmacist were acted upon for R#88, and R#40. Cross-reference F490: Administration. The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to ensure new interventions were in place to address resident-to-resident physical abuse by resident (R) #39 were communicated to all staff and a system was implemented to ensure the interventions were carried out to prevent further incident. Cross-reference F501: Responsibilities of the Medical Director. The medical director failed to assure care was provided that met current standards of practice in areas including resident-to-resident altercations and use of [MEDICAL CONDITION] medications. On 12/10/16 at 2:38 p.m., the Administrator stated the QA committee did not routinely discuss problem behavioral symptoms and did not review behavior tracking records. She stated the QA committee discussed the percentages of [MEDICAL CONDITION] medication use and the upcoming required dose reductions, but did not discuss use of PRN (as needed) [MEDICAL CONDITION] medications, implementation of non-pharmacological approaches prior to use of PRN medications, and monitoring for effectiveness of medications. She also stated the QA committee had not initiated any quality improvement projects related to behavior management or [MEDICAL CONDITION] medication use. The Administrator also stated the QA committee did not review abuse incidents, grievances, or reportable occurrences unless a trend or pattern was identified. She stated R#39 had not been discussed in QA because he has not had a reportable occurrence in a while. The Administrator sated the psychologist had done some education regarding behaviors, causes, interventions, and non-pharmacological approaches., but the QA committee had not identified a need for further education on this subject. She added the QA committee had not initiated any quality improvement projects related to resident-to-resident abuse or reportable occurrences. On 12/9/16 from 4:00 p.m. to 5:00 p.m., the Medical Director was interviewed. He stated he attended most monthly QA meetings, where all clinical issues were reviewed. He stated the committee attempted to identify any patterns or trends in their data and focused on those for further review. Cross reference F501: Medical Director. Interview 12/9/16 starting at 4 p.m. describing his goal to reduce the use of [MEDICAL CONDITION] medications, the use of these medications has increased dramatically with the influx of new residents with behavioral issues or psychiatric diagnoses. The clientele at the facility had become more aggressive and had more prevalence of polypharmacy. The QA committee did not review the use of [MEDICAL CONDITION] medications. The Medical Director was unable to state how the goal of reducing [MEDICAL CONDITION] medication use was addressed as a quality improvement project in the QA committee. The Medical Director also stated the QA committee did not consistently review incidents of resident-to-resident abuse unless there was a pattern or trend of increasing incidence. He stated R#39 had not been discussed in the committee, and there were no quality improvement activities initiated regarding protection of vulnerable residents from abuse. He stated the QA committee had never discussed or identified vulnerable residents who may be at risk of resident-to-resident abuse in the facility, especially since the influx of new residents with behavioral issues or psychiatric diagnoses, but felt it would be a good idea. On 12/8/16 at 2:55 p.m., the Administrator and Director of Nursing (DON) were alerted to the presence of an Immediate Jeopardy situation related to R#39's continued access to wire hangers and lack of staff education related to safety interventions for R#39. The facility implemented the following actions, per their credible AoC, to remove the Immediate Jeopardy: 1. On 12/8/16 at approximately 3:10 p.m., the resident determined to be the aggressor was placed on one on one supervision and facility social worker began seeking inpatient stabilization services for resident. At approximately 11:45 a.m. and 3:15 p.m. on 12/8/16, the resident's room was checked to ensure that no other potentially dangerous items were present. 2. On 12/8/16, the Administrator will purchase adequate plastic clothes hangers and on 12/9/16 at approximately 8:00 a.m., the Housekeeping and Laundry Supervisor will begin converting all resident closets to plastic clothes hangers and all wire hangers will be placed in dumpster for removal. 3. At approximately 5:30 p.m. on 12/8/16, the resident was transported to (the behavioral health hospital) for direct admission for stabilization. On 12/8/16 at approximately 5:15 p.m., the Care Management Team met and reviewed residents in house to determine any other at risk residents and no other risks were identified. The Administrator and/or designee will educate all staff immediately with mandatory in-servicing regarding the removal or wire coat hangers on 12/8/16 and will be continued until 100% completion. In-service is mandatory and wall (sic) employees will participate prior to reporting to work. As of 12/10/16 at 1:30 p.m., the facility has 96% completion for removal of wire coat hanger in services the facility has one LPN, one RN, and one dietary employee remaining to be in serviced the DO and will in-service staff concerning resident abuse and managing adverse behaviors, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 12/10/16. As of 12/10/16 at 1:30 PM, the facility is at 93% for the abuse in servicing we have remaining to nursing assistance to LPNs one RN and one dietary staff and 2 to inservice. 4. A quality assurance audit tool for physical/verbal or aggression was created on 12/9/16. Incidents of physically/verbal or aggressive behavior will be audited by the DON and or her designee using the quality assurance audit for physical/verbal or aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective on 12/9/16; any findings of noncompliance will be presented to the quality assurance committee monthly to determine if additional action is needed ongoing. Residents determined to be the aggressor will be placed on every 15 minute visual monitoring until the resident is stabilized or transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered in aggressor as of 12/9/16 and monitoring will occur every 15 minutes until the residents are stabilized or transferred to an inpatient psychiatric behavioral unit for evaluation. If the resident is the victim of the physically/verbal or aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 12/9/16 to include signs of symptoms of abuse, i.e., excessive crying, bruises, trembling, scratches, withdrawal, pain. If the resident is the victim of a physically/verbal or aggressive behavior the social services department will be notified and they will monitor the residence (sic) psychological wellbeing (sic) concerned in the resident as well as the resident's reaction to his or her involvement in the investigation social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 12/9/2016. During the seven-day period of visual monitoring if the resident exhibits physically/verbal or aggressive behavior without injury, to either party, every 15 minute, visual checks will be resumed until the resident is determined to be stabilized by the Care Management Team or transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually(/)physically aggressive behavior results in injury to either party, one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 12/9/2016. All residents with physical/verbal or aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the care management meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 12/9/2016. All residents with physical/verbal or aggressive behavior will continue to be evaluated by the facility contracted psychiatric group during their visits. The Administrator and director nurses (sic) will continue to be notified of any reports of physically or sexually aggressive behaviors immediately. The nursing staff will continue to complete incident reports for incidence (sic) of abusive behavior. Effective 12/9/2016. Care plan coordinator will be educated to implement revision of approaches and interventions to the plan of care related to both physical/verbal and aggressive behaviors by 12/9/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses or her designee as part of the weekly care management meetings. This education was completed at 100% on 12/9/16. Any resident that were not updated will be updated immediately during the weekly care management meeting effective 12/9/16. The surveyors validated the implementation of the AoC as follows: 1. R#39 was observed with one-to-one supervision from approximately 3:15 p.m. to 5:35 p.m., when the resident was sent out to the behavioral health hospital. The order to send the resident out and the Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health) were reviewed. R#39 had not returned to the facility by the close survey on 12/10/16 at 6:00 p.m. 2. On 12/9/16, the housekeeping staff was observed to replace all wire hangers in residents' rooms with plastic hangers. On 12/10/16, a 100% resident room audit was conducted and no wire hangers were observed. 3. The Care Management Team audit of residents at risk for physical aggression was reviewed. The in-service records from trainings on removal of wire coat hangers and on resident abuse and managing adverse behaviors were reviewed; 96% completion of the wire hanger removal in-service and 93% completion of the abuse and adverse behaviors in-service was verified as of 1:30 p.m. on 12/10/16. Interviews were conducted with the Social Services Director (SSD); Activity Director (AD); CNAs AY, AT, AG, AH, and AI; LPNs AE, AO, AF, and AB; Registered Nurses (RN) AB and AD; and the receptionist on 12/10/16 from 11:00 a.m. to 12:00 p.m., all of which confirmed the education was received and understood. 4. The quality assurance Audit Tool was reviewed, and will be completed going forward for any incident of resident-to-resident aggression. The education record of the MDS Coordinator (care plan coordinator) was reviewed on 12/10/16 and confirmed as completed. R#39 had not returned to the facility as of the survey exit on 12/10/16 at 6:00 p.m. | 2019-11-01 |
| 2026 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 490 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed the residents and the physical environment for elopement risks. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately 1/4 of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Observations, clinical records review, and staff interviews revealed that the facility was not in substantial compliance during the Abbreviated Extended Survey conducted [DATE] through [DATE]. Refer to the following deficiencies for specific details of the noncompliance. Cross reference to F278: Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. Cross reference to F280: Based on observation and interview, the facility failed to review and revise the care plan, assess the resident's responses to current care plan interventions and failed to get input from the resident or his/her representative to assess the reason for the elopement and develop new interventions to prevent future elopement attempts for one resident (R) #1. Cross reference to F323: Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. and no changes were recommended to R#1's plan of care. Post survey interview with the DON on [DATE] at 11:48 a.m. revealed that Facility does not believe any other interventions were necessary, no changes were made, so nothing was required follow-up. Residents were not assessed or re-assessed for elopement risks and no care plan revisions were made for R#1 related to elopement or elopement risk after R#1 eloped in (YEAR). The facility implemented the following actions to remove the Immediate Jeopardy 1. On [DATE] at 1:45 pm the Administrator initiated the Emergency Preparedness Missing person plan after being informed that staff could not locate patient R#1. The Administrator assumed the Incident Commander role and organized search teams to search the center, surrounding outside area and local areas surrounding the center. The Administrator directed the Director of Nursing and Assistant Director of Nursing to visually account for all residents in the center and all residents were accounted for. The Administrator directed the Maintenance Director to check all exit doors and gates to ensure that they were closed and locked. The Administrator directed the Regional Nurse to assist the Director of Nursing, Assistant Director of Nursing, and three Resident Care Coordinators to re-assess all residents for Elopement Risk. All residents were assessed for elopement risk and grouped according to high, medium and low risk status. All care plans have been reviewed and revised, if indicated, for all high and medium risk elopment status. 2. On [DATE] at 2:00 p.m. the Administrator notified the Candler County Sheriff's Office. The Sheriff's Office was on site at 2:15 p.m. and assumed the Incident Commander role and began to lead an extensive search for the patient that included: - A three-mile radius ground search using trained medical staff, law enforcement agents, K-9s. - A five to seven-mile radius air search using drones, two planes and a Helicopter with infrared capability. - Facility Staff placed calls and provided search description and pictures of R#1n to local emergency room s on Friday and Saturday; confirmed by RVP. - Facility Staff and volunteers searched on foot and car in surrounding areas; Confirmed by RVP, everyone was participating. - Facility staff and volunteers distributed flyers to private homes in area and local/surrounding businesses. - Flyers were faxed to local and surrounding emergency room s, Fire Departments, EMS and Private Ambulance/Transport Companies. ([DATE], [DATE] and [DATE] done by Human Resource Associate and patient transition directors) 3. On [DATE], the Administrator contacted R#1 physician and family. The Administrator provided contact information and updated status on law enforcement investigation. 4. On [DATE], the Administrator posted staff members at the exit door that was suspected that the resident exited until an audible alarm was placed on the door at approximately 5:00 p.m. Education provided included: In the instance that the alarm goes off, an employee is to get with another employee (go in pairs) and make rounds outside of the building, once inside the building, every patient is to be accounted for. Remaining staff members were educated on [DATE] by Administrator and Director of Nursing. 5. On [DATE], the Administrator called and Ad-hoc (imppromptu) QAPI meeting with the Director of Nursing, Assistant Director of Nursing, Financial Controller, MDS Coordinator, Food Service Manager, Social Services Director, Resident Care Coordinator, Maintenance Director, Environmental Services Supervisor, Human Resource Manager, Recreational Therapist, Regional Engineering and Safety Manager, Regional Vice President and Regional Nurse to review the incident, investigation measures and next steps. 6. On [DATE], the Administrator implemented a 1. Visitor Sign In/Out procedure. 2. Visitors will be given a document upon signing in that provides education regarding the safety and security of our patients. This will be an ongoing procedure. 7. On [DATE], the Regional Vice President 1. provided education to the Administrator on job description, roles and responsibilities and duty to ensure that the center uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient. 2. The Regional Vice President and the Regional Nurse provided education to the Administrator on the Wandering Patient Protocol (patient behavior should be reviewed with patient, responsible party, family members and interdisciplinary team; the center cannot inhibit the patient's leaving the center if he/she so chooses without a court-appointed guardian; the center should initiate efforts to protect the patient from injury; the center may have a door alarm system; Notify Administrator and Director of Nursing, local law enforcement, responsible party, attending physician; and Emergency Preparedness Plan for Missing Patients (Notify Administrator ASAP, Form Search Teams, Thoroughly search the premises, Notify the patient representative, notify the attending physician, notify the appropriate agencies). The Regional Vice President re-educated the Administrator on her role in the Quality Assurance Performance Improvement process. The Regional Vice President, Regional Nurse and Administrator reviewed the residents was performed to determine moving forward. In an effort to prevent reoccurrence of elopement, the Administrator was educate by the RVP and regional support teams on proper ways to ensure patient safety. 8. On [DATE], the Administrator and Director of Nursing provided education to center staff on elopement prevention and response - 4 of 5 RN' s, 13 of 14 LPN's, 28 of 33 C.N.A's, 1 of 1 Admissions Director, 7 of7 Dietary Staff, 7 of 9 Environmental Services, 1 of 1 Maintenance Director, 3 of 3 Activities, 1 of 1 Social Services, 1 of 1 Social Service Director, 1 of 1 Financial Controller, 1 of 1 Human Resource, and 1 of 1 Medical Records. Education provided included: How to assess the patient (focus on determine resident's purpose for attempting to leave), how to identify those at risk for elopement and identifying them, patient care plan (activity and social programs to occupy patients), Communication (resident sign in/out), Emergency Preparedness (Notify Administrator ASAP, Form Search Teams, thoroughly search the premises, Notify the patient representative, notify the attending physician, notify the appropriate agencies). 9. On [DATE], the Regional Vice President and Regional Engineering and Safety Manager made thorough environmental rounds to identify any potential risk factors and areas addressed as indicated. There were no noted potential risk factors or areas. All gates were locked and all doors were secure. The Regional Vice President and Regional Engineering and Safety Manager reviewed findings with the Administrator. 10. On [DATE] the Ad-hoc (impromptu) QAPI team will review the investigation to date and all interventions implemented to determine and additional mechanisms for preventing further occurrence. All findings will be entered the QAPI program and will be reviewed until compliance is achieved. The regional vice president will continue to provide ongoing education to the Administrator and any abnormal findings related to patient safety will be entered in the QAPI program until compliance is achieved. If any abnormal findings concluded, regional vice president will re-educate administrator and perform disciplinary action if needed. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Interview on [DATE] at 4:00 p.m. with Administrator revealed that she had initated the Emergency Preparedness on [DATE]. Record review revealed that Administrator completed actions per the Emergency Preparedness Missing Person Plan. Interview on [DATE] at 11:15 a.m. with DON and ADON revealed that they had accounted for all residents residing in the facility. Record review revealed that DON and ADON visually accounted for all patients in the center using the resident roster. Interview on [DATE] at 11:30 a.m. with Maintenance Director revealed they had ensured all exit doors and gates were closed at locked on [DATE]. Record review revealed that the Maintenance Director checked all exit doors and gates. Interview on [DATE] at 3:45 p.m. with Administrator revealed that the residents were re-assessed for Elopement Risks. Record review revealed that DON and ADON re-assessed all patients for Elopement Risk. Interview on [DATE] at 11:00 a.m. with DON, ADON, RAI Director, and RCC revealed that all residents were assessed for elopement risk and grouped according to status and care plans had been revised if indicated on [DATE] and [DATE]. Record review revealed that R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#12, R#13, R#14, R#15, and R#16 care plans have been updated and revised. Record review revealed on [DATE] the Administrator initiated the Emergency Preparedness Missing person plan, was the Incident Commander, and organized teams to search the center, surrounding area, and that all staff participated. All residents were accounted for except R#1, The DON/ADON re-assessed all residents for Elopement risk and grouped the residents according to risk of elopement for medium and high risks. 2. Interview on [DATE] at 2:05 p.m. with the Sheriff's Deputy and Georgia Bureau of Investigation and confirmed with the Administrator and Regional Vice President on [DATE] at 4:45 p.m. revealed Candler County Sheriff's Office Investigation Reports were contacted on [DATE] and that the investigation was pending. Record review revealed Candler County Sheriff's Office Investigation Reports were contacted on [DATE] and that the investigation was pending. 3. Interview on [DATE] at 4:00 p.m. with Administrator and Regional Vice President confirmed that the resident's family and physician were notified on [DATE]. Record review revealed that Administrator notified resident's sister and resident's physician on [DATE] at 2:00 p.m. 4. Interview on [DATE] at 11:00 a.m. with Regional Vice President, DON, CNA SSS, CNA CCC and CNA YY revealed that they had been educated on what to do when the door alarms went off. Record review revealed that staff members were posted by the door until audible alarm was placed on the door on [DATE] at 5:00 p.m. and that education was provided to the staff of the installation of the alarm and what to do if the alarm went off. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 a.m., CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by the Administrator. 5. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE]. 6. Interview on [DATE] at 11:45 a.m. with Regional Vice President revealed that visitors need to sign in and out of the facility. Record reviewed revealed visitors are required to sign in and out and patient safety education is being provided to visitors as they are signing in. 7. Interview on [DATE] at 9:20 a.m. with the Regional Vice President revealed they provided education to the Administrator on her job description, roles and responsibilities and duty to ensure that the center uses its resources effectively and efficiently. Record review revealed that Administrator was re-educated by Regional Vice President. 8. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans, and how to assess the patient, how to identify those at risk for elopement and identifying them, patient care plan, Communication, Form search teams, thoroughly search the premises, notify patient representative, and physician, and the appropriate agencies. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA at 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 a.m., CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by Administrator. 9. Interview on [DATE] at 4:00 p.m. with Regional Vice President revealed environmental rounds had been completed to ensure all doors and gates were locked. Record review revealed that environmental rounds were made by Regional Vice President and Regional Engineering and Safety Manager were completed on [DATE] and all gates were locked and doors were secure. 10. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE] and that findings will be reviewed until compliance is achieved and the Regional Vice President will continue to provide ongoing education to the Administrator. 10. Interview on [DATE] at 11:30 a.m. with Regional Vice President confirmed that an Ad-Hoc (impromptu) QAPI meeting was held on [DATE]. Record review revealed that a Performance Improvement Committee met at 1:00 p.m. on [DATE] and that findings will be reviewed until compliance is achieved and the Regional Vice President will continue to provide ongoing education to the Administrator. | 2020-09-01 |
| 1251 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 580 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to notify the physician and responsible party in a timely manner, of a change in condition for one resident (A) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's advance directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F868, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Advance Directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Change in Condition policy: When to report to the MD/NP/PA guidance. The form documented that immediate notification should be made of any symptom, sign or apparent discomfort that is acute or sudden in onset and is a marked change in relation to usual symptoms and signs or is unrelieved by measures already prescribed. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a physician's orders [REDACTED]. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. R A experienced a change in condition on [DATE]. Review of a Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., notified the physician at 7:15 a.m., and the resident's responsible party at 7:20 a.m. The DNR status that was documented on the MAR record, referenced in the [DATE] at 5:40 a.m. nurse's note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. Review of the form used on [DATE] by Licensed Nursing Staff, revealed DNR dated [DATE] with two residents listed, including R [NAME] There was no evidence that licensed nursing staff notified the physician or responsible party timely, of the resident's sudden change in condition, notification of EMS personnel, and initiation and cessation of CPR prior to EMS arrival and departure. During interviews on [DATE] at 1:45 p.m. and [DATE] at 12:46 p.m., the DHS confirmed that she notified the physician and R A's responsible party of his death, after she arrived at the facility. She further stated that when she notified them of the resident's death, she was unaware of the events that had occurred because they had not been reported to her. She stated that she did not become aware of the events that had occurred until Licensed Practical Nurse (LPN) UU entered the 9:30 a.m. morning meeting, on [DATE], and notified all staff, that were present, that R A's family member had called the facility stating the resident was a full code and inquiring about EMS. During an interview on [DATE] at 11:47 a.m., with the physician, he stated that licensed nursing staff did not call him when he would have expected them to call him, which is when the resident's condition is changing. He stated that the call from the DHS was the first call he received regarding R [NAME] Cross reference to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate advance directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy related to notification: The facility failed to notify the physician upon change of condition for Resident [NAME] The facility failed to notify the MD at the time of the incident because the LPN incorrectly identified that the resident was a DNR. The system that failed was the DNR system, The Social Worker (SSD) provided a DNR listing that was not accurate and the LPN failed to verify the code status in the resident chart. Although the DNR listing was found to be incorrect, the LPN failed to notify the MD at the time that Resident A had a change of condition. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1. The CCC and DHS were educated by the SNC on [DATE] on MD notification policy for change of condition. CCC and DHS educated active licensed staff of MD notification policy for change of condition on [DATE] and [DATE]. ,[DATE] LPNs have received education as of [DATE] (92%), ,[DATE] RNs completed as of [DATE] (87.5%). 2. Certified staff were educated on [DATE] to report change of condition to Nurse by the Administrator and DHS. ,[DATE] active CNAs completed education as of [DATE] (85%). 3. All newly hired licensed and certified staff will be educated on this policy upon orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA or PRN (as needed) status will not work until education is completed. 4. 24 hr reports will be reviewed daily x2 weeks by the DHS or Registered Nurse (RN) on call for change of condition to ensure MD notification conducted as required. Findings will be reported by the DHS in the QAPI meeting monthly x3 months. The State Survey Agency (SSA) validated the corrective actions taken by the facility as of [DATE] as follows: 1. An interview with the CCC on [DATE] at 12:01 p.m. and the DHS on [DATE] at 1:45 p.m. revealed that both had been educated by the SNC regarding MD notification policy for change of condition on [DATE] and on [DATE]. Review of the sign in sheets confirm the in-services. Verification of sign in sheets for Licensed Nurses confirmed that on [DATE], 20 licensed nursed had completed the in-service on Change of Condition with one nurse on [DATE]. 2. Review of the CNA sign-in sheets on Notification of Change revealed that on [DATE] and [DATE] that 30 of 34 CNA's had been in-serviced. 3. A interview with the CCC on [DATE] at 1:20 p.m. revealed the facility had one new hire, who was educated on [DATE]. Any staff returning to work or new hire must have the in-services prior to working with residents. 4. Review of the 24-hour report revealed these are reviewed by the DHS and signed as reviewed by the DHS. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed they had all be recently in-serviced on the policy and procedure for notifying the physician if a change in condition should occur, their role in the notification process in a timely manner. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in an in-service which included notification and their role in this process. | 2020-09-01 |
| 2025 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 323 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exercise class scheduled on [DATE] from 10:00 a.m. to 10:30 a.m. The facility realized that the resident was missing at approximately 1:10 p.m. when the kitchen staff observed that the resident's lunch tray was still on the serving cart. The resident's family, physician, and police were notified. Foot patrols were begun by the Sheriff's office and nursing home volunteers. Additional searches were conducted until [DATE], at approximately 1:30 p.m. when R#1 was found approximately a quarter of a mile from the facility, deceased . The immediate jeopardy was related to the facility's noncompliance with the program requirements at F 278 SS=J 483.20(g)-(j) Assessment Accuracy/Coordination/Certified, F280 S/S: J 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) Right to participate in planning care - Revise care plan, F 323 SS=J 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devises F 490 SS=J 483.70 Effective Administration/Resident well-being. Additionally, Substandard Quality of Care was identified with the requirements at F 323 SS=J 483.25(d) (1) (2) (n) (1)-(3) Free of Accident Hazards/Supervision/Devices. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident assessments related to elopement, updating and revising care plans, systematic review of residents and the physical environment for elopement risks. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Resident records were reviewed to ensure that resident care and treatment, including assessments and care plans were current and accurate. The IJ was removed on [DATE]. Findings include: Clinical record review for R#1 revealed the resident had the following diagnoses, including but not limited to: unspecified psychosis, generalized anxiety disorder, adjustment disorder, unspecified dementia, schizophrenia, and dementia with behavior disturbance. Review of R#1's Minimum Data Set (MDS) annual review dated [DATE] revealed under Section C - Cognition, that resident was severely cognitively impaired. Under Section [NAME] - Behaviors, R#1 is not coded for wandering behavior, but his previous MDS assessments from [DATE] through [DATE] were coded for wandering. Resident also had delusions, exhibited verbal behaviors ,[DATE] days of the review period and exhibited other behaviors ,[DATE] days of the review period. Under section G- Functional Status, the resident required supervision for most activities of daily living, but needed extensive assistance to dress and maintain personal hygiene. Review of the 'Interdisciplinary Progress Notes' dated [DATE] at 10:15 p.m. and recorded by nursing staff revealed an assessment for a fall that occurred on [DATE] with an additional notation that read: also, at 4:35 p.m. staff member alerted nurse that Mr. (R#1) had left the premises. Nurse writer and 3 other staff members went outside to search for him. Resident had waked (sic) about 1 mile down HWY 46 and was returned to facility by staff member. There were no injuries noted to body. Appeared to be in no distress. Resident showed nurse writer how he had gotten out. Apparently, while the heating and air service men were working on the unit they left the door open and Mr. (R#1) walked outside. Resident stated, I'm sorry, I was just trying to get home. Review of R#1's current 'Plan of Care' for wandering/elopement revealed it originated on [DATE] and had not been updated or revised related to the elopement on [DATE]. Interview with the Administrator on [DATE] at 1:40 p.m. revealed that R#1 eloped from the facility on [DATE] sometime after 10:45 a.m. Staff discovered the resident was missing at approximately 1:30 p.m., searched the facility, and notified the Administrator at 1:45 p.m. The Administrator alerted the local police and a search for the resident was initiated. Continuing interview with the Administrator revealed that the resident had successfully eloped previously on [DATE]. Exterior tour and interview on [DATE] at 11:35 a.m. with the Engineering and Safety Manager QQ reveals that all gates are padlocked with the exception of the front gate which is secured with a maglock. The fencing is approximately 4 1/2 feet tall, there are two types of fence, but no large gaps in between them. Engineering and Safety Manager QQ confirms that this is the same fencing that was in place in (YEAR). Engineering and Safety Manager QQ states that he never observed R#1 hanging around the secured doors, trying to get out of the building or trying to leave the secured exterior, but that the resident was known to observe the door codes. When asked how the facility addressed this, the Engineering and Safety Manager QQ stated that the door codes were changed when it was reported to him. Interview on [DATE] at 3:05 p.m. with Activities Director KK who confirmed that resident was with her for activities on [DATE]. Activities finished at 10:30 a.m. but that R#1 stayed with her to visit, until approximately 10:45 a.m. Activities Director KK revealed that she believed the resident exited through the secure door of the hall next to the dining room. That is where R#1 put his wheelchair prior to activities. Activities Director KK confirmed that R#1 did not need the wheelchair to ambulate, but was encouraged to use it because of his unsteady gait. Activities Director KK revealed that R#1 would have been able to see the contracted staff out the dining room window during that mornings activities, and also stated that when resident's family visited, he wanted to go home with them. Once they left, he was easily re-directed due to his short-term memory loss. Activities Director KK confirmed that he was pretty happy most of the time, liked to watch television, enjoyed smoke breaks and was involved with everything. He had problems with some residents when he wandered into their rooms. He was curious and impulsive and said that he wanted to learn to drive and get a car. He was aware that the doors locked and would try to catch them before they closed. Activities Director KK states that she never reported this because it was not new behavior for this resident. Interview with the Administrator and the Regional Vice-President on [DATE] at 10:45 a.m. revealed that R#1's [DATE] elopement was discussed during the scheduled Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] at 12:00 p.m. No changes were recommended to R#1's plan of care, at that time. The facility implemented monthly checks of the secured doors for functionality and security as an intervention and the door codes were changed as a precaution. Changes to the secured code for the doors occur 'as needed'. Monthly monitoring logs continue to be maintained of the secured door checks, but no monitoring of the efficacy of this intervention was recorded. Interview on [DATE] at 11:10 a.m. with the DON revealed that she confirmed that the resident had previously eloped in (YEAR) under very similar circumstances to the residents elopement on [DATE]. In (YEAR) the contractors were there to make repairs on the air conditioning units and the resident exited the building through the open gate. The DON further revealed that R#1 paid attention to the door codes and that he was probably able to let himself out. She further states that the facility made a policy change requiring that the secured doors be checked monthly after R#1's elopement in (YEAR). Further interview revealed that there was no follow-up or tracking tool used to measure the effectiveness of this intervention and that there was not a re-assessment completed for this resident or any of the other residents at risk for elopement. Continued interview with the DON revealed that the facility had no formal assessment tool to assess for risk for elopement, and that elopement risk assessments are not required by the facility and had not been conducted. Further interview with the DON revealed that was not aware that the resident attempted to 'catch' doors before they closed, but was aware that he had entered other resident's rooms and was known to observe staff entering the code to open the secured doors. Interview on [DATE] at 1:27 p.m. with the Georgia Bureau of Investigation's officer YY who confirmed that resident's remains were located on [DATE] by the Sheriff's department a short distance from the facility with no apparent foul play involved. Interview on [DATE] at 1:35 p.m. with Certified Nursing Assistant (CNA) EE who reveals she noticed the resident was not in the dining room in his spot and that his tray was still on the cart and notified R#1's assigned CN[NAME] She also states that she noticed the air conditioning contractors working because you could see them out the dining room window. She confirmed that activities are performed in the dining room and that the resident would have been able to see the air conditioning contracted staff working during activities. Interview on [DATE] at 1:45 p.m. with Engineering and Safety Manager QQ who confirmed that contractors were at the facility on [DATE] between the hours of 9:45 a.m. and 11:45 a.m. working in the attic on the air conditioners. Engineering and Safety Manager QQ also confirms that contractors are allowed to work unsupervised by facility staff. Interview with Maintenance Director NN on [DATE] at 3:15 p.m. revealed that the contractors entered into the attic opening to repair the drip pans on the AC. The gate was open for them to go back and forth for supplies, etc. The Maintenance Director stated that he told the contractors not to let anyone out and cautioned them regarding the residents. The gate was rolled closed, but not locked. Post investigation interview with the Administrator on [DATE] at 11:29 a.m. revealed that Engineering and Safety Manager QQ stated that he is the Regional Manager and is at this facility periodically. As the Safety Manager, he attended the Quality Assurance and Performance Improvement (QAPI) meeting on [DATE] that discussed when R#1 eloped and that is when he became familiar with R#1 and was told that the resident had been known to observe the door codes. Post survey interview on [DATE] at 10:34 a.m. with the owner of the HVAC company revealed that they arrived at the facility around 10:00 a.m. and completed their work at 12:00 p.m. He stated that they saw and spoke to no residents while they were working. The HVAC owner revealed that once they were completed he walked to the Administrator's office with the invoice and let her know they were finished. He stated that he walked back towards the dining area to use the that door to exit and the door had a key pad and needed a key code. A nurse was near-by and the nurse quietly told him the code to the key pad to exit out of the door. The HVAC owner stated that no residents were near him or the nurse when he had asked for and was given the code to the key pad. He revealed that when he exited the facility he did not see anyone outside. The HVAC owner revealed when they exited the gate that surrounds the facility they locked the gate before leaving the grounds. The facility implemented the following actions to remove the Immediate Jeopardy: Emergency Preparedness for Missing Patient Implemented on [DATE] by Administrator. 1. On [DATE] at 3:15 p.m., the Director of Nursing and Assistance Director of Nursing made rounds and made sure that every patient was accounted for. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, RAI Director, and both Resident Care Coordinator's recognized all patients who were at high risk for elopement. A current resident listing was printed and an elopement assessment was completed on each patient to determine if the patient was at high risk, medium risk, or low risk for elopement. 3. On [DATE], the Director of Nursing, Assistant Director of Nursing, and RAI Director reviewed care plans for every patient in the center and started making revisions where necessary. On [DATE], the RAI Director finished necessary care plan revisions. 4. On [DATE], the Administrator, Director of Nursing, and Regional Vice President held a mandatory staff meeting at 7:00 a.m. Education was provided to staff on how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits (there are a total of 7 entry/exit doors). All exit doors currently have a keypad that requires a protected key code to be entered in order to exit the center. Codes are changed monthly and as needed. Use of alarm placed on door that is suspected patient exited (if alarm were to sound, employee is to go with another employee to complete rounds of the outside of building to verify no one left the building, come back inside of the facility and account for every patient to ensure no one exited building), emergency preparedness in the event of a missing person, zone defense rounds (defense rounds include a list of every patient and all 7 entry /exit doors. The nurse assigned to the resident will verify that the resident is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure, and CNA care plan utilization (CNA care plan specifically for CNA's, example: Do they have a walker? Do they require assistance in toileting? 4 of 5 RNs, 13 of 14 LPNs, 28 of33 CNAs, 7 of 7 Dietary, 7 of 9 Housekeeping, 1 Service Director, 1 of 1 Financial Controller, 1 of 1 Human Resource Manager, 1 of 1 Admission Coordinators, 1 of 1 Administrator, and 1 of 1 Medical Record Manager have been in serviced, which is 87.2% of total staff. 5. There were staff that were unable to attend due to as needed (PRN) status (1 total), part-time status (3) and unable to attend who are full-time (4 total). These staff will be educated by Administrator, Director of Nursing, or Assistant Director of Nursing on how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits, use of alarm placed on the door where patient is suspected to have exited (if alarm were to sound, employee is to go with another employee to complete rounds of the outside of the building to verify no one has the left building, come back inside of facility and account for every patient to ensure no one exited building), emergency preparedness in the event of a missing person, zone defense rounds, ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure), and CNA care plan utilization (CNA care plan specifically for CNA, example: Do they have a walker? Do they require assistance in toileting?) 6. Interventions implemented by the facility include: Staff member sat and monitored door #5 that suspected patient exited on [DATE], (log kept) a door alarm was placed on door #5, [DATE]. Administrator and Engineering Safety Manager assessed the building entrances and exits to determine any risk factors for elopement (made sure that all gates were locked and doors were secure), Administrator interviewed the owner of the Heating, Ventilation, and Air Conditioning (HVAC) company on [DATE] and owner stated that he did not see the resident nor speak to the resident and confirmed that the additional 4 HVAC employees did not see or speak to the resident. On [DATE], all door codes were changed. Ad-hoc (impromptu) QAPI meeting held on [DATE] to determine mechanisms for preventing further occurrence (attendants include Administrator, Director of Nursing, Financial Controller, Assistant Director of Nursing, MDS Coordinator, Infection Control Nurse, Education Nurse, Food Service Manager, Social Service Director, Facility Management Supervisor, Environmental Services Supervisor, Patient Care Coordinator, Regional Vice President, Human Resource Manager, Regional Engineering Safety Manager, and Recreational Therapist), Assessments performed on all residents on [DATE]. All residents assessed per DON on [DATE] to determine if any additional residents are at high risk (findings did show that some residents who were previously considered low risk are now considered high risk) and resident specific interventions implemented as needed by RAI Director, on [DATE] RAI Director implemented specific interventions as needed for those residents recognized to be at high risk for elopement (Interventions include: Redirect resident if he/she becomes agitated when possible, Notify MD (DON spoke with him on Friday and discussed doors and QAPI) for further interventions when needed, if resident voices wanting to leave facility notify social services or charge nurse as needed, observe for suspicious behaviors of a possible attempt such as hanging in doorways or pushing on doors, talk with resident and attempt to redirect if noted to be confused about whereabouts as needed, redirect resident if possible, try to determine cause for agitation, involve resident in activities as will tolerate to redirect attention and thoughts, involve in activities such as bingo and music related, activities for diversion, praise resident for good behavior and staff members that resident might relate to better to further interventions, talk with resident about past experiences to provide diversion). Gates are documented checked twice a day to insure all gates are locked. All staff received education on [DATE] presented by the Administrator, Director of Nursing, and Regional Vice President on how to observe gates and make sure gates are locked at all times during the day. Facility follows same protocol for weekends and holidays. There are currently seven entry/exit doors. A temporary alarm was placed on suspected exit door #5 on [DATE], the remaining six doors will have a temporary alarm placed by the close of business [DATE]. Installation of permanent key pads with an alarm that alarms if door is opened longer than thirty seconds or if door is forced open will begin [DATE]. Anticipated completion date is Tuesday, [DATE]. Temporary alarms will remain on doors until all permanent alarms are placed and working. Door alarms are checked hourly during zone defense rounds completed by nurses responsible for residents located on that hall. All doors are locked and have a keypad that requires a protected code in order to be opened. The entire facility is surrounded with a fence that includes locked gates that must be unlocked in order to exit. Gate checks are completed twice a day to insure all are securely locked 7. The Administrator and the Director of Nursing will monitor the collected elopement data (elopement data is gathered from the elopement assessment tool providing information on does the patient attempt to elope? Do you see the patient attempting to get out the doors? Are you aware of the patient leaving the center without informing staff? Does the patient wander aimlessly? Does the patient express the desire to go home? Is the patient easily redirected? Are there any interventions that you find helpful with redirecting the patient when they may be seeking an exit?) Using the Elopement assessment tool (the elopement assessment tool asks the following questions on every resident to determine elopement risk: Do they attempt to elope? Do you see the patient attempting to get out the doors? Are you aware of the patient leaving the center without informing staff? Does the patient wander aimlessly? Does the patient express the desire to go home? Is the patient easily redirected? Are there any interventions that you find helpful with redirecting the patient when they may be seeking an exit?) for 6 weeks and review monthly during QAPI. New admissions and re-admissions will have an elopement risk assessment (elopement risk assessment ask the following: Does this resident have a court-appointed guardian? Does this resident have the cognitive ability to make relevant decisions? Does this resident have a history of escape or elopement? Does the resident have a related diagnosis dementia/depression/mental illness, Does the resident move around freely and independently with or without devices such as he/she wants to leave to go home, wander with or without devices such as he/she wants to 1 eave to go home, Does the behavior include risky behaviors such as trying to open doors) completed on him/her at time of admission to facility. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Interview with the Director of Nursing (DON) and (Assistant Director of Nursing (ADON) on [DATE] at 11:45 a.m. revealed that when R#1 was suspected to be missing from the facility on [DATE], Nursing made rounds and ensured that every patient was accounted at 3:15 p.m. Documentation was provided verifying that rounds were made at that time and that every resident excluding the eloped resident was accounted for. 2. On [DATE], the Director of Nursing, Assistant Director of Nursing, Resident Assessment Instrument (RAI) Director, and both Resident Care Coordinator's reviewed all residents who were at high risk for elopement. A current resident listing was printed and an elopement assessment was completed on each resident to determine if the resident was at high risk, medium risk, or low risk for elopement. An interview conducted on [DATE] at 10:38 a.m. with the Director of Nursing, Assistant Director of Nursing, and the Resident Assessment Instrument (RAI) Director and who confirmed that all facility residents were assessed for elopement risk. A current resident listing was provided and Record review revealed that an elopement assessment had been completed on every resident to determine if the resident was at high risk, medium risk, or low risk for elopement. 3. On [DATE], a current resident listing was printed and an elopement assessment was completed on each patient to determine if the patient was at high risk, medium risk, or low risk for elopement. A current resident listing and elope assessment risk for every patient in the center was provided on [DATE] at 10:38 a.m. On [DATE], the Resident Assessment Instrument (RAI) Director finished necessary care plan revisions and provided copies of the care plan revisions for residents assessed as high or medium risk. 4. A meeting was held with Administrator, Director of Nursing, Regional Vice President, Resident Assessment Instrument (RAI) Director coordinator on [DATE] at 10:35 a.m. who confirmed their presence in this meeting or that they were reached by telephone and that how to determine the difference between wandering and elopement, realistic goals and interventions for wandering and elopement, causes and risks of wandering and elopement, identifying and care planning those at risk for wandering and elopement, safety and security for those at risk for wandering and elopement, elopement drills, appropriate purpose and use of alarmed doors and exits. Summary of the training tool was provided for reference. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to determining the difference between wandering and elopement, about goals and interventions for wandering and elopement, the causes and risks for wandering and elopement, identifying and care planning residents that are at risk for wandering and elopement, providing safety and security for those at risk for wandering and elopement, elopement drills, the appropriate purpose and use of alarmed doors and exits, what to do if a door alarm does alarm, what to do in the event of a missing person, zone defense rounds, ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and utilizing the CNA care plans. These interviews were conducted on [DATE] as follows: LPN UU at 8:30 a.m., LPN VV at 8:45 a.m., CNA WW at 8:50 a.m., RCC Nurse Supervisor XX at 9:00 a.m., CNA YY at 9:40 a.m., LPN ZZ at 9:45 a.m., LPN AAA at 9:50 a.m., CNA BBB at 9:55 a.m., CNA CCC at 10:00 a.m., CNA DDD at 10:05 a.m., CNA EEE at 10:10 a.m., LPN FFF at 10:15 a.m., CNA GGG at 10:20 a.m., CNA HHH at 10:25 a.m., CNA III at 10:30 a.m., Housekeeper JJJ at 8:55 a.m., Housekeeper KKK at 9:00 a.m., Maintenance LLL at 9:05 a.m., Activity Director MMM at 9:10 a.m., Social Services NNN at 9:15 a.m., Human Resources OOO at 9:20 a.m., Medical Records PPP at 9:25 am, CNA QQQ at 10:35 a.m., CNA RRR at 10:45 a.m., CNA SSS at 10:45 a.m., Dietary Aide TTT 10:50 a.m., Dietary Aide UUU at 10:55 a.m., ADON DD, RAI Coordinator EE, Admissions FF, Human, Resources GG, Financial Controller, HH, RCC II, Activity Director KK, Social Services LL, Maintenance NN at 11:00 a.m. Record review of in-service sign in sheets revealed that 68 staff attended this in-service and 10 staff did not attend and were educated via phone by Administrator. Door codes for 7 doors (all facility exit doors) were changed on [DATE] at 3:00 p.m. Monthly code changes were confirmed during interview with Regional Engineering and Safety Manager on [DATE] at 12:10 p.m. and were again confirmed by the facility Maintenance Director on [DATE] at 10:38 a.m. Observation revealed that the temporary alarm mounted on door #5 was functional for both access and egress. Tour of the Gate perimeter and door rounds with the facility Maintenance Director on [DATE] 10:38 a.m. confirmed that gate rounds are made hourly and keypad doors have been monitored and recorded since at least (YEAR). Code changes are made monthly or as needed and are recorded. Both the Regional Engineering and Safety Manager and the Maintenance Director were able to articulate the new Zone Access Tool process and support this new tool. Interview on [DATE] at 9:50 a.m. the DON with who confirmed that Door #5 that an alarm was placed on door #5 on [DATE] at 2:05 p.m. and that the alarm is functional. Staff have been trained in the new Zone Defense tool and know what to implement if the alarm were to sound unexpectedly. An interview on [DATE] at 9:55 a.m. with LPN RR who revealed she would go with another employee, complete rounds of the outside of building to verify no one left building and come back inside and account for every patient to ensure no one exited building. She was able to explain emergency preparedness in the event of a missing person, zone defense rounds (defense rounds include a list of every patient and all 7 entry/exit doors. The nurse assigned to that resident will verify that the resident is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place (doing rounds to ensure all gates are locked and doors are secure). CNA's also participate and are responsible for care plan utilization of the CNA care plans, like identifying if the missing resident uses a walker, can walk unassisted, has a beard, etc. 5. Of the staff unable to attend on [DATE], two were on medical leave, one is a PRN employee, and three are part time and did not attend. All of these employees have since been trained as of the end of the day on [DATE]. This is evidenced by the sign in sheets and confirmed with interviews on [DATE] with the Director of Nursing and Assistant Director of Nursing on [DATE] at 10:38 a.m. 6. Review of the log book reveals that door #5 was secured and monitored until the door alarm was placed on [DATE] at approximately 5:00 p.m. In the event of a missing person, emergency preparedness zone defense rounds are initiated that include a checklist of every patient and review of all 7 entry/exit doors. The nurse assigned to that patient will verify that patient is accounted for and the gates will be divided among the 2 nurses to be checked and validated as secure), ensuring all safety measures are in place including rounds to ensure all gates are locked and doors are secure, and CNA care plan utilization such as specific resident CNA care plans: Does resident have a walker? Do they require assistance in toileting? Observation of Mock zone defense rounds on [DATE] beginning at 8:30 a.m., at 9:25 a.m. and again at 10:10 a.m. revealed that participating staff included housekeeping JJJ, KKK, LPN's Z, and AAA, CNA FFF, and activity director DD, maintenance LLL. Other staff observed and were asked questions about the process. Staff who were unable to participate were called and interviewed over the phone for the Zone Defense Tool including the following questions: in the event of a missing person, what protocol is followed? When are emergency preparedness zone defense rounds initiated and what do they include? Is there a check list of every patient and review of all 7 entry/exit doors? What does the nurse assigned to that patient do, how are the gates divided, checked and validated as secure? After all safety measures are in | 2020-09-01 |
| 3483 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 867 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews and policy review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system, to ensure advance directive documentation was maintained and accurate in the clinical record, in an effort to prevent errors or delays in emergency basic life support measures. The facility had a census of 86 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a [NAME] Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on (MONTH) 29, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Advance Directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: The facility had a Quality Assurance and Performance Improvement policy. The policy documented that the purpose of the Quality Assurance and Performance Improvement (QAPI) program was to continually take a proactive approach to assure and improve the way the facility provided are and engage with patients, partners, and other stakeholders so that the facility may fully realize their vision, mission and commitment to caring pledge. During an interview on [DATE] at 1:50 p.m., the Administrator revealed that she oversees the QAPI committee and they met on a monthly basis, on the third Wednesday of each month. The facility had an Advance Directive: Georgia policy and Do Not Resuscitate Policy: Georgia policy in place to address obtaining and maintaining resident Advance Directive information in the clinical record. However, there was no evidence that this system was routinely monitored through the QAPI process, to ensure that it was accurately and consistently implemented. During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. Further interview the Administrator confirmed that she was not aware of any concerns regarding Advance Directive completion and accuracy in the clinical record prior to R#4's and R#12's deaths. In response to the incident, she interviewed staff, called a Quality Assurance Performance Improvement (QAPI) meeting (on [DATE]), put a plan in place and began auditing residents' Advance Directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. 1. The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the facility's electronic clinical record system integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. 2. The Administrator or designee would complete a daily audit tool to monitor advance directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting Advance Directive documentation. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy. During Post survey review it was determined that the deficiency should be cited under F687: Facility must maintain a Quality Assurance Performance Improvement committee consisting of the Director of Health Services, Medical Director, Infection Prevention Committee, Administrator must meet quarterly to evaluate activities under the Quality Assurance Performance Improvement program. Root Cause Analysis Facility failed to identify the Advanced Directives on Resident #4 and Resident #12. 1) On (MONTH) 29, 2019 the Facility Administrator, Director of Health Services, Area Vice President, Senior Nurse Consultant, Assistant Director of Health Services, Unit Manager, MDS Coordinators, Housekeeping and Laundry Director, Social Services Director, Activities Director, Admissions Director, Admissions Coordinator, Clinical Competency Coordinator (CCC), Business Office Manager, Human Resources, Medical Records Coordinator, Senior Care Partner, Therapy Director, Wound Nurse (SNC) met in facility conference for immediate Quality Assurance Performance Improvement interventions to the cited incident. The Medical Director participated via phone for the Quality Assurance Performance Improvement and concurred with initial self-imposed interventions as detailed in the below A[NAME]. 2) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 3) Director of Health Services and Social Services completed an audit of all active resident records on [DATE] to ensure the Resident's Advanced Directives were in the medical records. 4) The Advanced Directive Clinical system checklist will be updated daily upon each new admission or change in Advanced Directives orders by DHS, unit managers or Social Worker. The Advance Directive auditing will be on-going. 5) Education compliance related to F655, F658, F678, F835, F842 and F868 (during QA review the deficiency was changed to F867) will be reported to Quality Assurance Performance Improvement by the Clinical Competency Coordinator monthly x3 months and quarterly thereafter as needed. All new staff hired will be educated on Advanced Directives in orientation. Title of Person Responsible for implementing the acceptable plan of correction: The Administrator is responsible for implementing the acceptable plan of correction. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of the sign in sheets of the [DATE] QAPI meeting confirmed the attendance of full committee. The Medical Director attended via telephone. Interviews were conducted on [DATE] at 12:33 p.m. with Clinical Competency Coordinator (CCC) CC, at 1:10 p.m. with the Human Resource (HR) Director and Financial Director, with the DHS at 1:15 p.m., with the Maintenance Director at 1:34 p.m., and with the Housekeeping supervisor at 1:50 p.m. confirming their attendance for the [DATE] QAPI meeting. 2. Review of the QA policy which was signed as reviewed by the Administrator on [DATE]. An interview with the Administrator on [DATE] at 2:32 p.m. to review the policy and confirmed that the policy was reviewed and approved by the QAPI members, then signed by the Administrator on [DATE]. 3. Review of the audit documentation and interview with the DHS on [DATE] at 1:15 p.m. verified the audit of all active resident records to confirm Advanced Directives were in the medical records. 4. Interviews on [DATE] at 1:15 p.m. with the DHS and ADHS verified the daily audit and update of Advanced Directives for new admissions or residents with a change in condition. 5. An interview with CCC CC on [DATE] at 12:33 p.m. verified that education has been completed and the results will be reported to the QAPI meetings, monthly and quarterly thereafter. She confirmed that all new staff hired will be educated upon hire. The facility has had no new hires since [DATE]. An interview with the Administrator on [DATE] at 2:32 p.m. verified that she was responsible for implementing the acceptable plan of correction. She also stated that since the A[NAME] had been written, 100% of staff had now been in-serviced. The QAPI committee had also had additional meetings on [DATE] and [DATE] to review the ongoing process (verified via review of sign-in sheets). | 2020-09-01 |
| 1203 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2019-09-16 | 684 | D | 1 | 0 | DP3B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews the facility failed to obtain medications in a timely manner for one resident (#2), and to administer medications as ordered for one resident (A) from a total sample of 12 residents. Findings include: 1. Resident (R) #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of Physicians Orders revealed the resident had medications that included [MEDICATION NAME] 5 milligrams (mg) once daily, [MEDICATION NAME] Extended two 100 mg capsules at bedtime, levetiracetam 1,000 mg twice daily, [MEDICATION NAME] 17 grams daily, and multivitamin with minerals once daily A review of the clinical record revealed that R#2 did not receive the [MEDICATION NAME] Extended on 1/27/19 at 9:00 p.m. as scheduled. A review of the (MONTH) 2019 Medication Administration History revealed that the medication was documented as not administered and drug/item unavailable. A nurse's note dated 1/28/19 at 1:51 a.m. documented that medications were not received from the pharmacy and that communication was sent to the pharmacy. The nurse note did not specify the type of communication sent to the pharmacy. A further review of the clinical record revealed that R#2 also did not receive the scheduled doses of [MEDICATION NAME], levetiracetam, [MEDICATION NAME], and multivitamin on 1/28/19 at 9:00 a.m., as ordered. A review of the (MONTH) 2019 Medication Administration History revealed that the medications were also charted as not administered and drug/item unavailable. During an interview on 9/16/19 at 2:10 p.m., the Administrator stated that the pharmacy sent out seven days worth of medications on 1/19/19, therefore the medications would have been out on 1/27/19 or 1/28/19. The pharmacy sent out an additional five days worth of medications on the night of 1/28/19. The facility maintained an Emergency Medication Kit. A review of the list of medications contained within the kit revealed that it included five doses of [MEDICATION NAME] 5mg, 10 doses of levetiracetem 250 mg, and five doses of [MEDICATION NAME] Extended ([MEDICATION NAME]) 100 mg. However, there was no evidence in the clincial record that nursing staff notified the Physician of the unavailable medications on the night of 1/27/19 or the morning of 1/28/19 and of the availability of medications in the Emergency Medication Kit. 2. Resident A had [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. The medications were scheduled to be administered at 9:00 a.m. and 5:00 p.m. A review of the clinical record revealed that R A did not receive the Artificial Tears, levetiracetam, [MEDICATION NAME], and [MEDICATION NAME] on 8/29/19 at 5:00 p.m. as scheduled. A review of the (MONTH) 2019 Medication Administration History revealed that the medications were documented as not administered and resident unavailable. A further review of the clinical record revealed that RA had left the facility for an outside appointment but had returned prior to the 5:00 p.m. medications being due. Nurses note entries on 8/29/19 documented that R A was out for a Physician's appointment at 12:32 p.m. but had returned to the facility at 4:26 p.m. During an interview on 9/16/19 at 12:17 p.m., a family member of R A stated that on 8/29/19, the night nurse Licensed Practical Nurse (LPN) BB) administer the resident's [MEDICATION NAME] (levetiracetam) because the day nurse (LPN AA) did not administer it. An 8/29/19 9:19 p.m. nurse's note documented that R A's family member phoned the facility stating that the resident informed her he had not received his 5:00 p.m. medications and was specifically concerned about the levetiracetam ([MEDICATION NAME]). The nurse's note, completed by Licensed Practical Nurse (LPN) BB, documented that she phoned LPN AA who confirmed that she did not administer the levetiracetam ([MEDICATION NAME]). The note further documents that LPN BB would pull the dose and administer it to the resident. However, there was no further information regarding the missed doses of the Artificial Tears, [MEDICATION NAME] and [MEDICATION NAME], nor evidence that the Physician was notified. During interviews on 9/10/19 at 3:35 p.m. and on 9/16/19 at 11:10 a.m., the Administrator confirmed that LPN AA did not administer R A's levetiracetam as scheduled at 5:00 p.m. on 8/29/19. She stated that the medication was administered later the evening, close to 8:00 p.m., by LPN BB on the next shift. During an interview on 9/16/19 at 12:53 p.m., LPN AA confirmed that she did not administer R A's 5:00 p.m. medications on 8/29/19 as scheduled. She stated when he returned to the facility, she was administering medications to residents but she forgot to go back and administer his medications. During an interview on 9/16/19 at 1:53 p.m., the Physician stated he could not recall if he was notified of the missed medications on 8/29/19, but would expect to be notified. | 2020-09-01 |
| 2471 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 677 | D | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided in a thorough manner for one of 15 residents (R#11) reviewed for ADL assistance. Findings include: R#11 had [DIAGNOSES REDACTED]. The resident was assessed on the 7/8/19 Quarterly Minimum Data Set (MDS) assessment has having communication and cognitive deficits and being dependent on nursing staff for ADL's including personal hygiene and bathing. A care plan, was in place, since at least 10/18/18, that included the resident had a self-care performance deficit in ADL's with an intervention for nursing staff to provide ADL assistance as needed and to anticipate and meet the resident's needs. However, the facility failed to ensure that the ADL's of personal hygiene and/or bathing were provided in a thorough manner. A review of nurses notes and respiratory notes revealed that on 7/6/19 R#11 was observed to have a fly flying around her face and additional insects on her neck, near her stoma and [MEDICAL CONDITION] site. The insects were removed and the physician was notified. The resident was removed from the room, showered, and reassessed to ensure no other insects were observed, then transferred to a different room. During an interview on 10/7/19 at 10:35 a.m. the Respiratory Therapy Director (RT) stated she was making her first rounds that morning on 7/6/19 and noted the gauze around R#11's [MEDICAL CONDITION] and stoma site was soiled, and as she was changing the gauze she noticed what looked like a maggot when she removed the gauze. RT stated that the resident had a large neck and extra tissue growth/flap near her stoma site, above it. LPN DD came into the room and assisted her to tilt the resident's head back, so she could then pulled up the skin and saw a few more of the insects. The RT Director stated that they had to hyper-extend the neck and separate the skin fold to see the additional insects. The RT director stated she did not realize how deep the skin fold was until it was separated. She further stated that when [MEDICAL CONDITION] care is provided by the RT's, four times daily, they would not normally hyperextend a person's neck. Cleaning the neck area would be something the CNA's would do when providing care such as baths. The RT also stated that flies had been an issue on the hall the resident resided on. A review of Vent Check [MEDICAL CONDITION] forms revealed that RT's had routinely assessed the resident's [MEDICAL CONDITION] site on 7/5/19 at 3:04 p.m., 8:49 a.m., 3:15 p.m. and 8:47 p.m. and on 7/6/19 at 2:32 a.m., prior to the Respiratory Therapy Director observing the maggot on 7/6/19 at 8:40 a.m. During an interview on 10/1/19 at 4:00 p.m., LPN DD stated that the RT Director called her into R#11's room on 7/6/19 and at first she did not see anything on the resident but then as she looked closer she saw a small white, worm-like wiggling insect. She stated that the RT Director pulled the resident's skin down on her neck and LPN DD saw five or six more of the insects. LPN DD stated that R#11 had creases and folds on her neck. She further stated that they removed the insects and she notified the physician and Director of Nursing (DON). LPN DD stated that the resident was removed from the room and showered, including washing her hair. They then reassessed her and moved her to another room, as instructed by the physician. LPN DD stated that she did not remember seeing flies in the resident's room that day but had noticed flies in the room on other days. During an interview on 10/8/19 at 12:45 p.m., LPN Unit Manager CC stated the CNA's would be responsible for cleaning the resident's neck and face during bed baths and showers. During a subsequent interview on 10/9/19 at 11:15 a.m. with LPN Unit Manager CC, documentation of showers provided to R#11 was reviewed. The Documentation Survey Report form included that, prior to 7/6/19, the resident had received a shower on 7/4/19. LPN Unit Manager CC confirmed that her initials were on the 7/4/19 shower documentation and that she would have bathed the resident's neck during that shower. There was no evidence in the clinical record that the resident's neck area was thoroughly bathed on 7/5/19, prior to the insects being observed on 7/6/19. Phone Interview on 10/10/19 at 12 p.m. with Physician HH concerning incident on 7/6/19. When asked if the bugs that were found on the resident's neck, near [MEDICAL CONDITION] posed a safety risk for her Physician HH stated that yes, but to what extent was highly debatable. He stated that it could pose an infection risk but that in his experience had seen them around eyes, noses, mouths and trachs before but he has not ever seen them get into a deep airway- never inside the body. | 2020-09-01 |
| 2472 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 686 | E | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented consistently for five of seven residents (R#10, R#9, R#2, R#13, and R#12) reviewed for pressure ulcers. Findings include: During an interview on 9/24/19 at 3:20 p.m., Treatment Nurse, Licensed Practical Nurse (LPN) FF stated the she started doing wound treatments at the facility at the end of (MONTH) and had provided treatments as ordered. She further stated that she had problems with documentation in the computer at times. When she provided a treatement, then would click off on it in the computer as being completed, the computer would spin and spin like it was taking a long time to accept/save, and that it happened often. LPN FF also stated that she had problems trying to input orders into the computer on her laptop and would usually have to use the computers at the nursing stations. LPN Treatment Nurse FF was not employed at the facility after 10/2/19. 1. Resident (R) #10 had [DIAGNOSES REDACTED]. In addition, an arterial doppler report, dated 7/6/19 documented moderate stenosis in the arterial system of the left lower extremity. The resident was assessed on the 7/22/19 Quarterly Minimum Data Set (MDS) assessment as having cognitive impairment, being nonambulatory, and ranging from needing extensive assistance to being dependent on nursing staff for Activities of Daily Living (ADL's). A care plan was in place, dated 8/20/19, that included that R#10 had the potential for skin impairment related to weakness and bowel and bladder incontinence with an intervention for nursing staff to monitor and document location, size, and treatment of [REDACTED]. However, nursing staff failed to monitor and document the location, size and treatment of [REDACTED]. R #10 had a pressure ulcer to the left hip that was initially assessed by the wound physician on 9/11/19. The initial assessment documented that the pressure ulcer was a stage 4 and measured 13.8 x 8 x 0.1 centimeters (cm), with 100% thick adherent devitalized necrotic tissue. A review of the clinical record revealed that prior to 9/11/19, weekly skin assessments had been completed on 9/2/19 and 9/9/19. The weekly skin assessments completed on 9/2/19 and 9/9/19 documented that the left and right hip were being treated by the wound nurse. However, there was no evidence in the clinical record or on the facility Skin Integrity Reports of a pressure ulcer assessment or what treatment was being provided for the left hip pressure ulcer before 9/11/19. On 9/11/19 the wound physician ordered Santyl ointment and a dry protective dressing be applied to the left hip pressure ulcer once daily for 30 days. However, a review of the clinical record, including the (MONTH) Treatment Administration Record (TAR), revealed no evidence that the physician ordered treatment was carried out until 9/19/19. After 9/19/19 the wound physician continued to routinely assess R#10's pressure ulcers. The 10/2/19 Wound Evaluation and Management Summary report from the wound physician documented the left hip pressure ulcer as improved, measuring 11.1 x 10.5 x 0.8 cm with 40% thick adherent black necrotic tissue and 60% granulation tissue. On 9/29/19 a Nurse Progress Note timed at 7:41 p.m. documented that the nurse was called to the resident's room at 2:30 p.m. and the nurse noted multiple white insects on the resident's right ankle. The nurse note further documented that a head to toe skin assessment was completed and the resident was transported to the shower and all wounds were redressed. Although the 9/29/19 nurse progress note documents the resident's right ankle, interviews on 10/1/19 at 2:25 p.m. with acting Director of Nursing (DON) BB, who was the previous Assistant DON, and on 10/8/19 at 4:37 p.m. with CNA KK, who were both present on 9/29/19, clarified that the insects were observed on the left lower extremity. A review of the clinical record, including wound physician's notes, physician's orders [REDACTED].#10 had daily dressing changes ordered for pressure ulcers to his lower extremities that included the right heel, top of the left foot, left lateral foot, and left medial foot. However, there was no evidence that pressure ulcer treatments were completed, as ordered, on 9/28/19, the day prior to the insects being found. During an interview on 10/1/19 at 4:45 p.m., the acting Director of Nursing (DON) BB stated that she spoke with LPN JJ by phone and he stated that he, along with a Certified Nursing Assistant (CNA), changed all of the resident's dressings on 9/28/19. During an interview on 10/8/19 at 4:37 p.m., CNA KK stated she assisted LPN JJ when he changed the pressure ulcer dressings to the resident's hips on 9/28/19, but she did not help change the dressings on his feet or see the nurse complete those. R#10 had a pressure ulcer identified to the left medial foot on 8/28/19. The wound physician assessed the pressure ulcer on 8/28/19 and documented it as a 1 x 2.4 x 0.1 cm Stage 3 pressure ulcer with 100% granulation tissue. The wound physician ordered a treatment of [REDACTED]. However, a review of the clinical record revealed no evidence of the treatment order being documented and carried out. A review of the (MONTH) through (MONTH) 2019 TAR's revealed evidence of physician ordered treatments being provided to additional existing pressure ulcers on the left lower extremity, including the left heel (until 8/15/19), left foot, and left lateral foot, but not the left medial foot. A review of the most recent Wound Evaluation and Management Summary report from the wound physician, dated 10/2/19 revealed that the left medial foot wound had merged with another left foot wound that was being treated. R#10 had a 5 x 5 x 0cm pressure ulcer identified to the right heel on 8/30/19. The wound physician assessed the pressure ulcer on 9/4/19 and documented it as a 5.2 x 5.7 cm Unstageable Deep Tissue Injury (DTI). The wound physician ordered [MEDICATION NAME] and a dry protective dressing be applied once daily. However, a review of the clinical record, including the (MONTH) 2019 TAR, revealed no evidence of that the physician ordered treatment was carried out until 9/19/19. A review of the clinical record and wound physician notes, revealed that R#10 had a history of [REDACTED]. A pressure ulcer was again identified on the left heel on 8/28/19. The 8/28/19 wound physician's Wound Evaluation and Management Summary note documented the pressure ulcer as a 1 x 2 x 0.1 cm Stage 3 with 100% granulation tissue. The wound physician ordered a treatment of [REDACTED]. However, a review of the clinical record revealed no evidence that the physician ordered treatment was being carried out. A review of the (MONTH) through (MONTH) 2019 TAR's revealed evidence of physician ordered treatmentes being provided to additional existing pressure ulcers on the left lower extremity, inlcluding the left foot and left lateral foot, but not the left heel. The most recent wound physician report from 10/2/19 documented no change in the wound progress from the previous week's assessment. During an interview on 10/9/19 at 8:40 a.m., the wound physician stated that when he gives the nurses orders, he expects those orders to be entered (into the clinical record) and followed. He confirmed that the left medial foot pressure ulcer had worsened and combined with another existing left foot pressure ulcer. He stated that he was unsure why the left foot wounds were worsening, that it could be due to age, nutrition, blood supply or treatements not being done. He stated that the resident was not eating and felt that he would have been appropriate for hospice services but the family did not want hospice services. He stated that he suspects nursing staff were providing treatments. Further interview with the Wound Physician regarding the white insects revealed that the Wound Physician stated that they can have a positive impact because they eat dead tissue but when they are used medically they are sterile versus something flying into the dressing but the Wound Physician stated he was not personally concerned about it. During an interview with R#10's primay physician, he stated that he expected the nurses to carry out the orders given by the wound physician. The physician stated that given the resident's advanced age, terrible [MEDICAL CONDITION] and poor nutrition along with his immobility and it was understandable that the resident developed the pressure ulcers. He added that nursing staff couldn't change his position in bed enough to prevent them. 2. R#9 had [DIAGNOSES REDACTED]. A care plan was in place that included that the resident had potential and actual impairment (of skin) to the right upper back on 8/20/19 and to the right ishium on 9/25/19. The care plan included an intervention for nursing staff to provide weekly rounds with the wound team with measurements. However, there was no evidence in the clinical record that the pressure ulcer to the right ishium was assessed with [REDACTED]. A review of the Skin Integrity Reports for R#9 revealed that a pressure ulcer was identified to the right ishium on 9/24/19. The pressure ulcer is documented on the report as measuring 2.8 x 2 x 0.1 cm with a 100% necrotic wound bed. During an interview on 9/30/19 at 3:20 p.m., LPN tx nurse FF, clarified that the necrotic tissue was not black eschar, but was green. She stated that the wound physician would be evaluating it on the following Wednesday, 9/30/19. However, there was no evidence in the clinical record that the wound physician or facility nursing staff assessed the pressure ulcer to the right ishium after 9/24/19, until 10/9/19. During an interview on 10/9/19 at 8:40 a.m., the wound physician stated he was not made aware of the pressure ulcer to the right ishium until 10/9/19 and assessed it and debrided the necrotic tissue. R#9 also had a pressure ulcer to the right upper back. A review of the clinical record, facility Skin Intergrity Reports, and the wound physician's notes revealed conflicting documentation concerning the description of the pressure ulcer and treatments obtained prior to the wound physician assessing it on 8/28/19. The pressure ulcer was first assessed on the Skin Integrity Report by LPN Treatment Nurse FF on 8/21/19 as being unstageble but with a 100% granulation wound bed and measuring 2.5 x 1.4 cm x unmeasurable depth. However a Skin/Wound note from the day before, on 8/20/19 documents a late entry and includes that the resident is being followed by the wound team for necrosis of the right upper back with measurements of 1.5 x 1.3 x 0.2 cm. A further review of the clinical record revealed that prior to the 8/20 and 8/21/19 wound assessments, a open area to the right upper back was noted on a weekly skin assessment completed on 8/16/19 but with no further description or documented action taken. In addition, an 8/17/19 Change in Condition Evaluation form was completed that documented a skin wound or ulcer to the right side of the mid back that started on 8/16/19. The form also notes that the clinician was notified and recommended a dressing be applied and wound care nurse notified. However, there is no evidence in the clinical record ,including on the (MONTH) 2019 TAR, of what treatment order was obtained and carried out until after 8/28/19. On 8/28/19 the wound physician assessed R#9's pressure ulcer to the right upper back as unstageable with thick adherent devitalized necrotic tissue, and measuring 1.5 x 1.3 x 0.2 cm. The wound physician ordered a treatment of [REDACTED]. A review of the (MONTH) TAR revealed that the treatment order was added on 8/29/19 and documented as being provided. During an observation on 10/1/19 at 8:25 a.m. with LPN Treatment Nurse FF, the resident was observed to have a pressure ulcer to the right ishium and right upper back. The pressure ulcer to the right ishium was noted to be open, with yellow slough covering the wound bed. The pressure ulcer to the right mid back was observed to be open with a mixture of granulation tissue and slough to the wound bed. During the interview with the wound physician on 10/9/19 at 8:40 a.m., he stated that R#9 wanted to sit up for long periods of time without lying down. He stated that he had talked to her about this but that she still wanted to sit up (in the wheelchair). 3. R#2 had [DIAGNOSES REDACTED]. A care plan was in place that included that the resident was at risk for skin breakdown due to impaired mobility and cognition and incontinence with an intervention for licensed nursing staff to provide treatments as ordered. R#2 had been receiving hospice services since 3/29/19. On 7/19/19, the hospice nurse assessed the resident and documented three pressure ulcers and obtained treatment orders. The resident was assessed as having a 2.4 x 1.3 cm unstageable pressure ulcer with slough to the mid-coccyx, a 1.1 x 0.6 stage 2 to the right uppr buttock, and a 0.5 x 0.4 cm stage 2 to the coccyx. The physician's orders [REDACTED]. However, a review of the clincial record and hospice records revealed that the physician ordered treatments were not provided consistently. A review of the (MONTH) 2019 TAR revealed that the treatment orders for the three separate pressure ulcers were not listed on the TAR as three separate orders ,but as two treatment orders, one for the right buttock and one for the sacrum. A further review of the clinical record and hospice documentation revealed no evidence that treatments were provided every two days as ordered between 7/19/19 and 7/24/19 and between 7/24/19 and 7/30/19. On 7/30/19 the hospice nurse documented on the Visit Note Report that the dressing to the wound on the buttocks was dated 7/24/19. R#2's pressure ulcers resolved by 9/4/19. During an observation on 9/24/19 at 3:20 p.m. with LPN Treatment Nurse FF, the skin was observed to be intact to the buttocks and coccyx. 4. Resident #12 (R#12) admitted to the facility on [DATE] with a pressure ulcer wound to his sacrum. He entered the facility with [DIAGNOSES REDACTED]. R#12 is severely cognitively impaired and totally dependent on the staff for his care and treatments. Review of the Treatment Administration Records (TARs) for his unstageable deep tissue injury (DTI) to his sacrum wound revealed the following missing documentation of treatment days: June 2019 6/8/19, 6/15/19, 6/16/19, 6/23/19 and 6/29/19 July 2019 7/5/19, 7/6/19, 7/7/19, 7/11/19, 7/12/19, 7/14/19, 7/15/19, 7/16/19, 7/17/91, 7/19/19, 7/20/19, 7/23/19, 7/24/19, 7/25/19, 7/26/19, 7/27/19, 7/29/19, 7/30,/19 and 7/31/19 August 2019 8/1/19, 8/2/19, 8/3/19, 8/4/19, 8/5/19, 8/8/19, 8/9/19, 8/14/19, 8/15/19, 8/16/19, 8/17/19, 8/18/19, 8/19/19, 8/20/19, 8/21/19, 8/22/19, and 8/23/19 September 2019 9/13/19, 9/14/19, 9/15/19, 9/22/19, 9/27/19 and 9/28/19 October 2019 10/2/19 and 10/3/19 Review of the TARs for his unstageable deep tissue injuries to his bilateral elbow wounds revealed the following missing documentation of treatment days: June 2019 6/29/19 and 6/30/19 July 2019 7/5/19, 7/11/19, 7/14/19, 7/20/19, 7/23/19 7/28/19 and 7/29/19 August 2019 8/16/19, 8/18/19 and 8/22/19 September 2019 9/27/19 October 2019 10/3/19 Review of the nursing progress notes reveals inconsistencies of dressing changes/treatments. Nursing Progress Note dated 9/20/19 at 14:51, Late Entry: Note Text: No wound care done, dressings were soiled and dated from the 16th. This note does not indicate if this was the sacrum or elbow wounds. Nursing Progress Note dated 9/21/19 at 8:22 a.m., Late Entry: Note Text: wounds are still dressed with the bandage from the 18th and are all soiled and have not been changed. No wound care done. This note does not indicate if this was the sacrum or elbow wounds. Nursing Progress Note dated 9/25/19 at 14:53, Late Entry: Note Text: no wound care done, dressings were dated from 9/23/19 and soiled. This note does not indicate if this was the sacrum or elbow wounds. During an interview with the wound care physician on 10/9/19 at 8:20 a.m., he stated that sees R#12 weekly. He also stated that this is the first time he was made aware that the documentation for R#12's wounds was incomplete on the part of the facility. He stated that this resident has multiple co-morbidities and is very medically compromised. He then stated that R#12's wounds were slowly healing and he believed they would get better but very slowly. He stated that the facility had been through several wound care nurses and things have fallen off the plate. He suspected that wound care was done more often than it was documented because he sees this resident's wounds getting better. During an interview with LPN Hall Nurse, GG, on 10/9/19 at 12:31 p.m., she stated she was tired of finding dressings that were soiled and that had not been changed. She stated that at one time she found supplies in a resident room like the dressing change was set up to be done and then it was left undone. She stated she just started helping out with the facility wounds when her job was done on the hall passing medications etc. She stated she would feel like she is abandoning these residents if she didn't help all that she could. 5. Resident #13 (R#13) was admitted to the facility on [DATE] with a right heel and right leg pressure ulcer wound. Other [DIAGNOSES REDACTED]. Resident #13 is able to make her needs and desires known to staff and others and is moderately dependent on staff for her activities of daily living (ADL). Review of the Treatment Administration Records (TARs) for her right leg wound revealed the following missing documentation of treatment days: September 2019 9/13/19, 9/14/19, 9/15/19, 9/16/19. 9/22/19, 9/28/19, and 9/29/19 October 2019 10/2/19, 10/4/19 and 10/5/19 Review of the TARs for her right heel wound revealed the following missing documentation of treatment days: September 2019 9/13/19, 9/14/19, 9/15/19, 9/16/19, 9/22/19, 9/27/19, 9/28/19 and 9/29/19 October 2019 10/2/19, 10/4/19 and 10/5/19 During an interview with R#13 on 10/7/19 at 1:05 p.m., she stated she was waiting to have her wounds dressed. She stated they usually do her dressing changes but sometimes she has to remind them to do it. During an interview with one of the hall nurses, LPN, GG, on 10/9/19 at 12:31 p.m, she stated that not having the wound dressings completed has been a problem for along time. She stated that she manages one of the halls in the building but helps with the wounds when she is able. She also stated that either they were done at night by the Director of Nursing, when she would return to the building or they just didn't get done. | 2020-09-01 |
| 2470 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 656 | E | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented consistently for four of seven residents (R#10, R#9, R#2 and R#14) and failed to ensure that Activities of Daily Living (ADL) assistance was provided in a thorough manner for one of 7 residents(R#11) reviewed for pressure ulcers. Findings include: During an interview on 9/24/19 at 3:20 p.m., Treatment Nurse, Licensed Practical Nurse (LPN) FF stated the she started doing wound treatments at the facility at the end of (MONTH) and had provided treatments as ordered. She further stated that she had problems with documentation in the computer at times. When she provided a treatement, then would click off on it in the computer as being completed, the computer would spin and spin like it was taking a long time to accept/save, and that it happened often. LPN FF also stated that she had problems trying to input orders into the computer on her laptop and would usually have to use the computers at the nursing stations. 1. Resident (R) #10 had [DIAGNOSES REDACTED]. In addition, an arterial doppler report, dated 7/6/19 documented moderate stenosis in the arterial system of the left lower extremity. A care plan was in place, dated 8/20/19, that included that R#10 had the potential for skin impairment related to weakness and bowel and bladder incontinence. The care plan included an intervention, also dated 8/20/19, for nursing staff to monitor and document location, size, and treatment of [REDACTED]. However, nursing staff failed to monitor and document the location, size and treatment of [REDACTED]. R #10 had a pressure ulcer to the left hip that was initially assessed by the wound Physician on 9/11/19. The initial assessment documented that the pressure ulcer was a stage 4 and measured 13.8 cm x 8cm x 0.1 centimeters (cm), with 100% thick adherent devitalized necrotic tissue. A review of the clinical record revealed that prior to 9/11/19, weekly skin assessments had been completed on 9/2/19 and 9/9/19. The weekly skin assessments completed on 9/2/19 and 9/9/19 documented that the left and right hip were being treated by the wound nurse. However, there was no evidence in the clinical record or on the facility Skin Integrity Reports of a pressure ulcer assessment or what treatment was being provided for the left hip pressure ulcer before 9/11/19. On 9/11/19 the wound Physician ordered Santyl ointment and a dry protective dressing be applied to the left hip pressure ulcer once daily for 30 days. However, a review of the clinical record, including the (MONTH) Treatment Administration Record (TAR), revealed no evidence that the Physician ordered treatment was carried out until 9/19/19. On 9/29/19 a Nurse Progress Note timed at 7:41 p.m. documented that the nurse was called to the resident's room at 2:30 p.m. and the nurse noted multiple white insects on th resident's ankle. The nurse note further documented that a head to toe skin assessment was completed and the resident was transported to the shower and all wounds were dressed. A review of the clinical record, including wound Physician's notes, physician's orders [REDACTED].#10 had daily dressing changes ordered for pressure ulcers to his lower extremities that included the right heel, top of the left foot, left lateral foot, and left medial foot. However, there was no evidence that pressure ulcer treatments were completed, as ordered, on 9/28/19, the day prior to the insects being found. During an interview on 10/1/19 at 4:45 p.m., the acting Director of Nursing (DON) BB stated that she spoke with LPN JJ by phone and he stated that he, alon with a Certified Nursing Assistant (CNA), changed all of the resident's dressings on 9/28/19. During an interview on 10/8/19 at 4:37 p.m., CNA KK stated she assisted LPN JJ when he changed the pressure ulcer dressings to the resident's hips on 9/28/19, but she did not help change the dressings on his feet or see the nurse complete those. R#10 had a pressure ulcer identified to the left medial foot on 8/28/19. The wound Physician assessed the pressure ulcer on 8/28/19 and documented it as a 1 x 2.4 x 0.1 cm Stage 3 pressure ulcer with 100% granulation tissue. The wound Physician ordered a treatment of [REDACTED]. However, a review of the clinical record revealed no evidence of the treatment order being documented and carried out. A review of the (MONTH) through (MONTH) 2019 TAR's revealed evidence of Physician ordered treatments being provided to additional existing pressure ulcers on the left lower extremity, including the left heel (until 8/15/19), left foot, and left lateral foot, but not the left medial foot. R#10 had a 5 x 5 x 0 cm pressure ulcer identified to the right heel on 8/30/19. The wound Physician assessed the pressure ulcer on 9/4/19 and documented it as a 5.2 x 5.7 cm Unstageable Deep Tissue Injury (DTI). The wound Physician ordered [MEDICATION NAME] and a dry protective dressing be applied once daily. However, a review of the clinical record, including the (MONTH) 2019 TAR, revealed no evidence of that the Physician ordered treatment was carried out until 9/19/19. A review of the clinical record and wound Physician notes, revealed that R#10 had a history of [REDACTED]. A pressure ulcer was again identified on the left heel on 8/28/19. The 8/28/19 wound Physician note documented the pressure ulcer as a 1 x 2 x 0.1 cm Stage 3 with 100% granulation tissue. The wound Physician ordered a treatment of [REDACTED]. However, a review of the clinical record revealed no evidence that the Physician ordered treatment was being carried out. A review of the (MONTH) through (MONTH) 2019 TAR's revealed evidence of Physician ordered treatmentes being provided to additional existing pressure ulcers on the left lower extremity, inlcluding the left foot and left lateral foot, but not the left heel. Cross refer to F686 2. R#9 had [DIAGNOSES REDACTED]. A care plan was in place that included that the resident had potential and actual impairment (of skin) to the right upper back on 8/20/19 and to the right ishium on 9/25/19. The care plan included an intervention for nursing staff to provide weekly rounds with the wound team with measurements. However, there was no evidence in the clinical record that the pressure ulcer to the right ishium was assessed with [REDACTED]. A review of the Skin Integrity Reports for R#9 revealed that a pressure ulcer was identified to the right ishium on 9/24/19. The pressure ulcer is documented on the report as measuring 2.8 x 2 x 0.1 cm with a 100% necrotic wound bed. During an interview on 9/30/19 at 3:20 p.m., LPN Treatment Nurse FF, clarified that the necrotic tissue was not black eschar, but was green. She stated that the wound Physician would be evaluating it on the following Wednesday, 9/30/19. However, there was no evidence in the clinical record that the wound Physician or facility nursing staff assessed the pressure ulcer to the right ishium after 9/24/19, until 10/9/19. During an interview on 10/9/19 at 8:40 a.m., the wound Physician stated he was not made aware of the pressure ulcer to the right ishium until 10/9/19 and assessed it and debrided the necrotic tissue. Cross refer to F686 3. R#2 had [DIAGNOSES REDACTED]. A care plan was in place that included that the resident was at risk for skin breakdown due to impaired mobility and cognition and incontinence. The care plan included an intervention for licensed nursing staff to provide treatments as ordered. R#2 had been receiving hospice services since 3/29/19. On 7/19/19, the hospice nurse assessed the resident and documented three pressure ulcers and obtained treatment orders. The resident was assessed as having a 2.4 x 1.3 cm unstageable pressure ulcer with slough to the mid-coccyx, a 1.1 x 0.6 stage 2 to the right uppr buttock, and a 0.5 x 0.4 cm stage 2 to the coccyx. The physician's orders [REDACTED]. However, a review of the clincial record and hospice records revealed that the Physician ordered treatments were not provided consistently as care planned. A review of the (MONTH) 2019 TAR revealed that the treatment orders for the three separate pressure ulcers were not listed on the TAR as three separate orders ,but as two treatment orders, one for the right buttock and one for the sacrum. A further review of the clinical record and hospice documentation revealed no evidence that treatments were provided every two days as ordered between 7/19/19 and 7/24/19 and between 7/24/19 and 7/30/19. On 7/30/19 the hospice nurse documented on the Visit Note Report that the dressing to the wound on the buttocks was dated 7/24/19. Cross refer to F686 4. R#11 had [DIAGNOSES REDACTED]. A care plan, dated 10/18/18, was in place that included the resident had a self-care performance deficit in ADL's. The care plan included an intervention for nursing staff to provide ADL assistance as needed and to anticipate and meet the resident's needs. However, the facility failed to ensure that the ADL's of personal hygiene and/or bathing were provided, as care planned, in a thorough manner. A review of nurses notes and respiratory notes revealed that on 7/6/19 R#11 was observed to have insects on her neck, near her stoma and [MEDICAL CONDITION] site. The insects were removed and the resident was removed from the room, showered, and reassessed to ensure no other insects were observed. During an interview on 10/8/19 at 12:45 p.m., LPN Unit Manager CC stated the CNA's would be responsible for cleaning the resident's neck and face during bed baths and showers. Cross refer to F677 5. Resident #14 (R#14) admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14 was admitted with a pressure ulcer to her sacrum and on 9/15/19 a pressure ulcer was found on her left upper arm. Review of R#14's care plan revealed that the facility was not following the plan of care put in place for him noting treatments were not provided as ordered by the physician. Review of the care plan reveals the focus of: The resident has potential/actual impairment to skin integrity of the sacrum. Date initiated 9:14/19, Revision on 10/8/19. The goals of this plan of care is written as, The resident will be free from injury to sacrum through the review date. Date initiated 9/30/19, Revision on: 10/8/19 and Target Date of 1/6/20. The Interventions/Tasks written for this resident were: low loss air mattress (initiated on 10/8/19), Treatment (Tx) as ordered (initiated 10/8/19), weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (initiated on 9/30/19). The (MONTH) 15, 2019 treatment order for her pressure ulcer wounds was noted to be: [MEDICATION NAME] Wound/Burn Dressing Gel (Wound Dressing) apply to sacrum and left upper arm topically one time a day for wound care. Start 9/15/19, Discontinue 9/17/19. There is no order or evidence to support that this wound order was discontinued on (MONTH) 17, 2019. There is no new order for treatment for [REDACTED]. The Treatment Administration Record (TAR) reveals no orders, no treatment signatures completed for R#14's pressure ulcer wounds were conducted from (MONTH) 17, 2019 through (MONTH) 2, 2019. On (MONTH) 2, 2019 the order on the TAR reads cleanse area to sacrum and left upper arm with wound cleanser, pat dry and cover with a dry dressing MWF one time a day every Mon, Wed. Fri. for wound care. This new order leaves off the [MEDICATION NAME] Wound/Burn Dressing Gel component for the treatment of [REDACTED]. During an interview with the LPN Unit Manager, CC, on 10/9/19 at 11:12 a.m, she stated that when the order for treatment was discontinued on 9/17/19 the wound care nurse did not enter the new wound order as written by the wound physician on 9/18/19 to keep the treatment of [REDACTED]. During the time frame of (MONTH) 18, 2019 through (MONTH) 30, 2019 there is no documentation on the TAR that there was wound order in place or that her wound was being treated. | 2020-09-01 |
| 1432 | PRUITTHEALTH - FORSYTH | 115418 | 521 CABINESS ROAD | FORSYTH | GA | 31029 | 2019-11-04 | 880 | E | 1 | 0 | C2JS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to maintain an infection control program that included thorough and complete surveillance for four residents (#12, #7, #11 and #8) of six residents treated with an antiparasitic medication between (MONTH) and (MONTH) 2019. Finding include: During an interview on 10/29/19 at 10:00 a.m. the Administrator confirmed that the facility had some residents who had experienced rashes and that the facility was thinking the cause was environmental. A review of the timeline of interventions implemented by the facility revealed that the following interventions had been implemented: 1)The concentration of detergent used in washing machine for laundry was decreased on 5/31/19 2) The washing machine was serviced to ensure proper chemical flushing on 5/31/19 3) Dermatologist consultations were obtained as ordered 4) Steroid medications were implemented as ordered 5) Body audits were completed on all residents on 9/15/19 6) Topical medication treatments were obtained as ordered 7) Ivermectin (antiparasitic) medication use was implemented as ordered 8) Deep cleaning of rooms as scheduled 9) Mattresses were inspected 10) Medications were reviewed verbally with the pharmacist the week of 10/14/19 11) [MEDICATION NAME] baby products including soap and lotion were added to the affected residents 12) Hospice Certified Nursing Assistants (CNA's) were asked not to bring in products 13) Ecolab was consulted for the use of any other available detergents A review of the pharmacy list of residents who were dispensed Ivermectin, an antiparasitic medication, for use, revealed five Residents (R) (#3, #10, #11, #12, and #7). A sixth resident, R#8, was also identified as receiving Ivermectin between (MONTH) 2019 and (MONTH) 2019. A review of the Line Listing for Infections, a part of the facility's Infection Control Program, revealed that R#3 and R#10 were included in the (MONTH) and (MONTH) line listings respectively for the use of the anti-parasite medication, Ivermectin, for a rash. R#3 visited the dermatologist on 3/27/19 and returned with an order to take six 3 milligram (mg) Ivermectin tablets in one single dose, then repeat it in one week and wash all bed linens the morning after taking the medication. A 3/27/19 Nurse Practitioner (NP) note documented that the resident had a papular rash to the neck, trunk and upper extremities. The NP also documented the rash was possibly scabies and that the resident saw the Dermatologist that day and received orders for Ivermectin. R#10 had a 4/17/19 NP note that documented a papular rash to the anterior trunk and extremities. On 4/22/19 the physician documented that the rash was still present and would be treated empirically for scabies with Ivermectin. A physician's orders [REDACTED]. R#12 was included in the line listing for (MONTH) for a symptom of itching. However, the listing for R#12 was not complete to include the medication treatment. In addition, R#7 and R#11 also received treatment with Ivermectin in (MONTH) 2019 but were not included in the line listing for that month. In addition, R#8 is not included in the line listing for (MONTH) 2019. 1. A review of the clinical record for R#12 revealed a 7/8/19 12:10 p.m. nurse note that documented the physician was notified of continued itching and small red rash-like bumps covering all extremities and trunk. A new order for Ivermectin was obtained. The physician ordered to administer six, 3 mg tablets of Ivermectin in one single dose, and repeat the dose again in one week. A review of the Medication Administration History for (MONTH) 2019 confirmed that the resident received the ordered doses of Ivermectin on 7/9/19 and 7/16/19. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#12 is included on the list for a symptom of itching. However, the remaining information on the line listing is incomplete. The entry does not include information on cultures, treatment, if the treatment was [MEDICATION NAME], if there is a true infection, the site of the itching or if it was a nosocomial or community acquired infection. 2. R#7 had physician's orders [REDACTED]. The resident was seen by a dermatologist on 5/1/19 and 5/15/19 and [DIAGNOSES REDACTED]. The orders for the [MEDICATION NAME] cream and [MEDICATION NAME] cream continued. A review of the 6/26/19 NP notes revealed that the NP documented the resident had no rash during that visit. However, on 7/8/19, the NP documented complaints of pruritic rash to the trunk and upper extremities. An [DIAGNOSES REDACTED]tous rash and scratch marks were noted to the trunk and upper extremities. The NP note documents that the resident was seen by dermatology twice and diagnosed with [REDACTED]. The NP notified the physician and documented they would treat with Ivermectin to see if there was any improvement. An order was written on 7/8/19 for licensed nursing staff to administer six 3 mg tablets of Ivermectin once on 7/8/19 and repeat the dose on 7/15/19. A review of the Medication Administration History for (MONTH) 2019 confirmed that the resident received the ordered doses of Ivermectin on 7/8/19 and 7/15/19. A further review of the clinical record after the completion of the Ivermectin revealed no further evidence of a recurrence of the rash. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#7 was not included in the listing for the rash and treatment with Ivermectin. 3. R#11 was examined by the NP on 7/2/19. A review of the 7/2/19 NP progress note revealed that the resident had a complaint of itching and rash. The skin was documented as having an [DIAGNOSES REDACTED]tous papular rash to trunk and extremities. The assessment and plan section noted pruritis and [MEDICAL CONDITION], scratching non-stop. A 4 mg intramuscular dose of [MEDICATION NAME] was ordered and six, 3 mg tablets of Ivermectin were ordered for a one-time dose, and to be repeated in one week. A follow up NP note on 7/8/19 documented that the resident's contact [MEDICAL CONDITION] rash and pruritis had improved with Ivermectin and that the next dose was due that week. Additional physician's orders [REDACTED]. An additional follow up NP note for a 7/16/19 visit documented that the contact [MEDICAL CONDITION] had resolved with treatment. A further review of the clinical record after the completion of the Ivermectin revealed no further evidence of a recurrence of the rash. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#11 was not included in the listing for the rash and treatment with Ivermectin. 4. R#8 was examined by the NP on 5/21/19. A review of the 5/21/19 NP progress note revealed that the resident complained of pruritis and had a papular rash to the arms and anterior chest wall. The note includes that the issue was discussed with the physician and a decision was made to treat the resident with Ivermectin. A physician's orders [REDACTED]. A review of the Medication Administration History for (MONTH) 2019 does not include documentation that the resident received the medication as scheduled. On 6/4/19, the physician visited the resident and documented that the resident continued to complain of an itching rash. His note included that the family indicated it seemed to have started after clothes were washed at the facility, instead of at home and that the family would wash the resident's clothes at home again. An order was written for [MEDICATION NAME] 1% cream to be applied twice daily. On 6/23/19 the NP visited and documented that the resident had no complaints of a rash that day and that the facility was washing laundry in a special detergent and to continue with [MEDICATION NAME] cream as needed. On 7/15/19 the NP documented that the rash had resolved. On 8/24/19 the NP again documented few erythemous, papular [MEDICAL CONDITION] noted on the trunk with a [DIAGNOSES REDACTED].#8 continued to complain of itching and a dermatology referral was made. The presence of the [MEDICAL CONDITION] was also noted on an 8/28/19 NP note. The resident visited the Dermatologist on 9/18/19. A 9/18/19 3:53 p.m. nurse's note entry documented that the resident returned from the appointment with new orders for [MEDICATION NAME] cream for suspected scabies. The note further includes that the NP called the dermatologist and the dermatologist stated that no scabies were seen. On 9/20/19 the NP documented that the resident had no rash noted but had scaly [MEDICAL CONDITION] to the dorsal surface of both hands. The NP noted that R#8 went to the dermatologist earlier in the week and was given a prescription for [MEDICATION NAME] cream for suspected scabies. The note includes that the resident was previously treated with Ivermectin. The NP note documents that the issue was discussed with the resident's family and the family declined treatment with the [MEDICATION NAME] cream and that nursing staff were to continue to use Lac-Hydrin lotion, cortisone cream and [MEDICATION NAME] medications as needed. On 10/30/19 the NP documented that the [MEDICAL CONDITION] had resolved. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#8 was not included in the listing for the rash and treatment with Ivermectin. | 2020-09-01 |
| 340 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 835 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of clinical records it was determined that the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. Resident #1 injured his finger on 12/27/18. The Administrator was unaware of the extent of the injury until 1/4/19. The facility census was 123. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR:483.21(b)(1)Develop/Implement Comprehensive Care Plan (F656 Scope and Severity: J) CFR:483.21(b)(3)(i)Services Provided Meet Professional Standards (F658 Scope and Severity: J) CFR:483:25 Quality of Care (F684 Scope and Severity: J) CFR 483.70 Administration (F835 Scope and Severity: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25 Quality of Care (F684 Scope and Severity: J). Finding include: On 1/30/19 at 4:00 p.m. interview with former Administrator CC revealed that he was the Administrator at the facility from 6/1/17 until 1/16/19 and had recently been reassigned to another position in the facility. He revealed that he was unaware of R#1 injury and the dressing treatment until 1/4/19 after the resident was admitted to the hospital. He revealed that the Director of Nursing (DHS) and staff responded to the incident to prevent a further incident by removing all the self-adhering dressing from treatment carts. The Administrator stated he informed the phlebotomist not to leave any of the dressing behind after drawing resident's blood for the lab. He later followed up with a family member on the status update of the residents health. During an interview on 1/30/19 at 4:05 p.m. with the current Interim Administrator revealed that he started working at this facility on 1/16/19. During an interview on 1/31/19 at 2:02 p.m. the Regional Vice President stated that he and his team which includes: The Clinical Vice President, State Operation Manager as well as the Regional Consultant is overseeing and working directly with the facility on a daily basis to ensure that the A[NAME] is developed and ensure that the agreement with the State is carried out. He also stated that the current Interim Administrator at the facility agreed to stay on as the Administrator until he replaced. The expectation of hiring a permanent Administrator should be within the next 30 days. and ask that if he can be any service to call him directly. During a post survey interview on 2/13/19 at 2:15 p.m. Administrator CC it was clarified that he was notified of the incident regarding R#1 on 1/1/19 by Physician BB. Continued interview with Administrator CC it was learned that he did not attend the facility's Clinical Morning Meetings. Refer to F 656, F 658, F 684 | 2020-09-01 |
| 4998 | UNIVERSITY NURSING & REHAB CTR | 115467 | 180 EPPS BRIDGE RD | ATHENS | GA | 30606 | 2016-02-03 | 309 | D | 1 | 0 | 1G5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and the facility records, the facility failed to ensure that one (1) Licensed Practical Nurse (LL) dispense the correct medication to one (1) resident (K) of the sampled nineteen (19) residents. Findings include: Interview on 2/1/16 at 1:40 pm with Licensed Practical Nurse (LPN) LL revealed that she had gotten pain medication for another resident. She revealed that the resident's medication was 400 mg of [MEDICATION NAME]. She revealed that she put the resident's medication on resident K bedside table. She revealed that resident K was doing something in her room and then she came around her and picked up the other resident medication ( [MEDICATION NAME] 400 mg) . She revealed that she do not leave medication at the resident's bedside table. The nurse revealed that she was in a hurry and it was her fault, she checked the vital signs,and monitored the resident the rest of the shift. She revealed that resident K takes a lot of pain medication; but, she did not have any pain medication the rest of the shift. She revealed that she notified the resident's daughter, notified Medical Doctor. The nurse revealed that she has had in-services on medication dispensing. She revealed that she had medication in-services during orientation. Interview on 2/1/16 at 1:50 pm of resident K revealed the medication was sitting on the table. She revealed that the nurse left the soon because she had something to do. She revealed that she thought that the medication was hers, so she took it. She revealed that she did not get sick from the medication. She revealed that the staff took good care of her and continues to take good care of her. She revealed that the staff is good at the facility. She revealed that it was her fault that she took the wrong medication. Resident ambulating in room. Review of the In-service Summary and Attendance Record dated 11/26/15 indicated an in-service on the topic: Medication Administration & documentation of Med errors. It further indicated that HH attended. Review of the Occurrence Type dated 11/3/15 through 2/1/16 indicated an internal investigation of a medication error to resident K by LPN HH. | 2019-02-01 |
| 5153 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2015-12-10 | 309 | D | 1 | 0 | SFD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, and record reviews the facility failed to administer five (5) doses of IV [MEDICATION NAME] as ordered by physician for one (1) resident BB out of a random sample of three (3) residents Findings include: Record review of record for resident BB is a [AGE] year old male admitted to Golden Living Center (GLC) on 09/18/15. Resident has a history of ,[MEDICAL CONDITION].-difficile ([MEDICAL CONDITION]) and acute osteo[DIAGNOSES REDACTED]. Resident BB has a double lumen PICC line in right upper extremity. He was admitted on intravenous (IV) [MEDICATION NAME] every day (QD). Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. 9/19/15. 9/20/15, 9/21/15, and 9/22/15. Record review of nurse's notes dated 09/19/15 at 12:30 p.m. revealed that the nurse spoke at length with resident's spouse concerning medication concerns as doses missed from hospital to here. Doctor notified of missed doses. Interview conducted with Licensed Practical Nurse CC on 12/10/15 at 1:00 p.m. who stated she recalled the wife of resident BB informing the staff of the five (5) missed doses of IV [MEDICATION NAME]. CC further stated upon reviewing the physician's orders [REDACTED]. Interview conducted on 12/10/15 at 1:20 p.m. with the Director of Nursing (DON) revealed she investigated the event and discovered the omissions were due a medication transcription error resulting in five (5) missed doses of IV [MEDICATION NAME]. The nursing staff were educated on the facility policy regarding proper medication administration and transcription procedures and a copy of this training has been placed in their individual Human Resources (HR) file. She further stated it is her expectation that each nursing staff member be aware of the policies as written and adhere to the policies in their daily practice. | 2018-12-01 |
| 2513 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2018-09-27 | 580 | D | 1 | 0 | KB6111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, clinical record review and review of facility policy, the facility failed to notify the required entities for one (1) of 21 sampled residents (R) (R#197). R#197's hospice provider was not notified after the resident had a change in condition. The findings included: Review of R#197's clinical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of R#197's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. According to the assessment, R#197's life expectancy was less than six months and she received hospice services. Review of R#197's Hospice care plan dated 6/9/18 revealed the following: Focus: admitted on hospice care due to [DIAGNOSES REDACTED]. Intervention: Assess for pain, restlessness, agitation, constipation and other symptoms of discomfort; medicate as ordered and evaluate effectiveness; bereavement service provided by hospice as needed to help with grief and loss; support to resident and family including caregivers and other residents; center staff will notify hospice of significant changes, clinical complications needing P[NAME] (plan of care) change; code status DNR (do not resuscitate); provide ADL (activities of daily living) support, companionship and other interventions as desired by resident; and provide resident with food and fluids as desired for physical and emotional support. Review of R#197's Risk Management System report dated 7/3/18 revealed the resident had a fall on this date; however, the time of the fall was not documented. Licensed Practical Nurse (LPN) JJ obtained the resident's vital signs post fall at 3:15 p.m. (Temperature - 98.6 degrees, Pulse - 91, Respirations - 20 and Blood pressure 151/74). The report noted the resident was transported to the hospital via ambulance at 10:30 p.m. The circumstances of the event were documented, as follows: Staff heard a noise in resident room and intervened to find her on the floor behind the door. She was lying flat on her back with her head pointing towards the foot of the bed. She was noted to have sustained an abrasion to her right index finger. No further injuries noted from the fall, right index finger cleaned, and band aid applied, resident denies pain. The root cause of the incident was noted to be ambulating without her walker. Review of R#197's Neurological Assessment Flow Sheet dated 7/3/18 noted neurological checks were done to monitor for risks of a head injury related to the unwitnessed fall. Assessments were done on this date at 6:30 p.m., 7:00 p.m., 7:30 p.m., 8:00 p.m., and 9:00 p.m. All results were within normal limits. Review of R#197's Progress Notes dated 7/3/18 noted a change in condition has been noted. The symptoms include: Fall 07/03/2018 in the afternoon .Change reported so Primary Care Physician 7/3/18 at 7:30 a.m. (sic) .Orders obtained include: Neuro checks/monitor Other redirect resident to use her walker. According to the note, the resident's family was also notified of the fall. Interview in the facility's conference room on 9/25/18 at 12:09 p.m. with LPN JJ revealed on 7/3/18, R#197 had an unwitnessed fall, and she, another LPN and a Certified Nursing Assistant (CNA) picked the resident up from the floor and placed her in her bed. LPN JJ stated once R#197 was in the bed, she completed a head-to-toe assessment. The nurse said the only injury sustained was to the resident's finger. She further stated she called the resident's doctor and family to inform them of the fall. LPN JJ stated the resident continued resting in bed comfortably with no complaints of pain. The family came in about an hour later, closed the resident's door and stayed for a while, and then left the facility. Shortly after the family left, the resident's hospice services called the facility and asked what was going on. It was at this time that LPN JJ informed the hospice provider of R#197's fall. Telephone interview on 9/25/18 at 6:26 p.m. with R#197's son revealed he received a call from the facility on 7/3/18 around 6:00 p.m. informing him that his mother had fallen. After arriving at the facility about an hour later, he found his mother non-responsive and unable to open her eyes. The son said he and his wife stepped outside and called hospice to inform them of the resident's fall. The hospice nurse instructed the family to call 911 and have R#197 taken to the emergency room . Telephone interview on 9/26/18 at 11:18 a.m. with Hospice Representative (HR) ZZ revealed they received a call from R#197's son and daughter-in-law on 7/3/18 at 7:20 p.m. informing them the resident had fallen. The facility did not inform them of the resident's fall. Follow-up interview on 9/26/18 at 1:40 p.m. with LPN JJ while on the 100-hall said she did call the resident's doctor and son, and LPN JJ confirmed she did not notify hospice services after the resident's fall on 7/3/18. LPN JJ said I can't say why, but I would have called them before the end of shift. LPN JJ acknowledged R#197 had a change in condition because before the fall R#197 was constantly walking around, and after the fall the resident remained in bed. Review of the facility's policy titled Hospice revised on 3/1/18 noted that the facility must immediately notify hospice of a significant change in the patient's mental, physical, social, or emotional status . | 2020-09-01 |
| 2968 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 600 | J | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review, review of written statements, review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property and review of the police report, it was determined that the facility failed to ensure that one of 14 residents (R#7) was free from sexual abuse, and the facility failed to provide protection for one of 14 residents (R#7) causing continued fear after an allegation of sexual abuse was made on 6/8/19. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately reported the incident to two Licensed Practical Nurses (LPN). However, the LPN's failed to immediately report the incident to Administration which lead to a failure to protect R#7 resulting in R#6 re-entering her room again on (MONTH) 9, 2019 which caused R#7 continued fear. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). A Removal Plan was received on (MONTH) 26, 2019 related to 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600) and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans was implemented therefore, the immediacy of the deficient practice was removed on (MONTH) 28, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of ensuring that staff and residents are educated on the facility's abuse policy and know what abuse is, when to report abuse, and how to report abuse. This oversight process included the analysis of the facility staffs' conformance with the facility's abuse policies and procedures governing the timely and accurate reporting of abuse and implementing interventions in their abuse policy. In-service materials and records were reviewed. Observations and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility policies and procedures regarding what is abuse and when and how to report abuse. Findings include: A review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property documented the following procedure: Any allegation, suspicious, or identified occurrence involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. Record review revealed that R#6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 5/15/19, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was also assessed as requiring minimal assistance from staff. The resident was independent for locomotion on and off the unit and utilized a wheelchair and walker for mobility. Record review revealed that R#7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed that R#7 was assessed by the facility on the 5/4/19 MDS as having a BIMS score of six indicating that the resident was severely cognitively impaired with decision making skills and demonstrated inattention. The resident required extensive assistance of one person for bed mobility and was non-ambulatory. She was totally dependent on staff for dressing, hygiene and bathing. She was assessed as having functional limitation in range of motion of the upper extremity on one side and impairment on both sides of the lower extremities. Review of the care plans for R#7 revealed that the resident had a care plan dated 2/27/19 with a review date of 5/16/19 with the problem/need: Resident has difficulty expressing ideas or wants related to effects of disease process: mild intellectual disability and cognitive communication deficit. The approaches were to: Allow resident plenty of time to respond, speak to resident in a low, clear voice to increase chance of hearing, provide a quiet environment for resident when discussing important issues and resident can best understand simple, direct communication. There was also a care plan problem/need with a revision date of 2/27/19 for decreased ability to speak and understand due to poor cognitive ability with an approach for restorative nursing for training and skill practice for communication. During an interview with LPN BB (7 a.m.- 7 p.m. shift) on 6/18/19 at 4:08 p.m., revealed that on Saturday, 6/8/19, after 7:00 p.m., a CNA came and reported to LPN AA that R#6 was kissing R#7 on her face and that he had his hand under the covers. LPN BB stated she and the other nurse, LPN AA, went down to R#7's room and asked R#6 to leave. LPN BB stated that R#6 got mad and called them racists. Further interview with LPN BB revealed that on 6/9/19 around shift change she was walking by R#7's room and her eyes met R#7's eyes. LPN BB stated that R#7 looked fearful. LPN BB stated that she saw that R#6 was in the room talking to R#7's roommate and then R#6 went over to R#7's bed. LPN BB stated that R#7 continued to have a fearful look on her face. LPN BB stated she went into the room and asked R#7 if she wanted R#6 in her room, and R#7 responded, no. LPN BB stated she then asked R#6 to leave, and that R#6 got mad and left. Continued interview with LPN BB revealed that on 6/9/19 she told the Acting Assistant Director of Health Services (AADHS) that R#6 had been in R#7's room twice and that R#7 was fearful. After that, CNA DD told the AADHS what occurred on 6/8/19, when they saw R#6 in R#7's room kissing her on the face with his hand under the covers. LPN BB stated that the AADHS said Oh my God, that has to be reported. During an interview with Certified Nursing Assistant (CNA) CC on 6/18/19 at 5:05 p.m., she stated on Saturday evening, 6/8/19, she and CNA DD were passing out snacks and saw R#6 in R#7's room with his hand under the covers, whispering to the resident and kissing her on the face. She stated she went and reported it to LPN AA and went down to the room with another CN[NAME] LPN AA asked R#6 to leave the room. CNA CC stated R#6 got mad and called them racists. CNA CC stated that on 6/9/19, she talked to the police when they came to the facility. During an interview with CNA DD on 6/18/19 at 5:15 p.m., revealed that on 6/8/19, around 7:30 p.m., she and CNA CC were passing out snacks when they passed by R#7's room they saw R#6 in the room with his hand under the covers and he was kissing R#7 on the face. CNA DD stated after they went and reported this incident to LPN AA, they (CNA CC, CNA DD, LPN AA, and LPN BB) went back down to R#7's room. CNA DD stated that after R#6 was asked to leave, R#7 said she was scared, pointed to her privates and started crying. CNA DD stated that the next day, on 6/9/19, she had just clocked in when LPN BB stated she had just run R#6 out of R#7's room again. Further interview with CNA DD revealed that she was not told to keep an eye out for R#6 until after 6/9/19, when the Acting Assistant Director of Health Services (AADHS) told them to. During a telephone interview with LPN AA (7 p.m.-a.m. shift) on 6/19/19 at 11:35 a.m., revealed that LPN AA stated that she was taking report with the day shift nurse on 6/8/19, around 8:00 p.m., when the CNA's (CNA CC and CNA DD) came to her and said R#6 had his hands under R#7's covers. When LPN AA and LPN BB went to R#7's room she (LPN AA) asked R#6 to leave the room. LPN AA stated that R#7 told her that he touched her, but she did not specify where. LPN AA stated she examined R#7 and noticed her brief was on tight and there was no redness or swelling. LPN AA also stated that R#6 was in R#7's room morning, noon, and night but that she had never witnessed any behaviors prior to the 6/8/19 incident. LPN AA stated she did not report this to anyone because she thought the residents were boyfriend and girlfriend. Further interview with LPN AA revealed that the next night, on 6/9/19, when she came on duty LPN BB told her that R#6 had been in R#7's room again and that she (LPN BB) made him leave. Continued interview with LPN AA revealed that on 6/9/19, as they (LPN AA and LPN BB) were talking, the AADHS walked up and heard their conversation. LPN AA stated the AADHS called the Administrator who came out to the facility that night around 7:30 p.m. LPN AA stated the police also came out to the facility that night. Review of the written statement from the AADHS provided to the police department on 6/9/19 documented the following: R#7 informed this writer that a male resident, R#6, touched in private area while in her room last night. R#7 states I asked him to stop and he was kissing me on my face, saying don't be scared, I am not going to hurt you. R#7 states that she started to cry, and he told her he would give her some chips, actually she said he used the term pay her with some chips. Not to cry or be scared. R#6 complains of hurting in her privates. She (R#7) states, I am scared of him, he said he would be back in the weekend again. R#7 reported incident to two staff members on the night of Saturday, (MONTH) 8, 2019. Staff members walked into the room during said incident. A police report dated 6/9/19 documented the following: On 6/9/19 at 1951 hours (military time for 7:51 p.m.) 911 dispatched officers to (facility) in reference to a possible sexual assault. The AADHS walked with me (officer) to R#7's room where I asked her some questions about what had happened. I spoke softly and slowly to R#7 as I asked her questions. I asked if she could tell me what happened. She could not carry on a conversation, so I had to ask direct questions to get a response. She made the following statements. I love him, Told him to leave me alone, He was going to pay me back for the chips, He said he loved me, Told him to stop and he didn't stop, He was going to see me this weekend, I told him to stop touching me this morning, He didn't stop touching me, He was touching me with his hands and He was touching in the private. I then spoke with CNA's DD and CC. Both stated they were giving out snacks when they saw resident #6 standing by R#7's bed kissing her face while his hands were under the cover rubbing her. They stated they got nurse AA to come to the room and she told him to leave so they could check on the resident and he got upset. I then spoke with nurse BB and she stated she was walking by R#7's room around 6:00 p.m. this day 6/9/19 and saw R#6 in R#7's room. She stated she stood in the hallway and watched R#6 as he spoke with R#7's roommate about the Lord and gave her a honeybun. She stated R#6 started to talk to R#7 and she had a scared look on her face. She stated she asked her if she wanted the man in the room and she shook her head no. She stated she then asked R#6 to leave the room. Record review revealed that on 6/9/19, there was a physician's order to send R#7 to the emergency room for evaluation and treatment. Review of the Emergency Documentation dated 6/9/19, documented in the physical exam, a visual inspection of the patient's skin reveals no evidence of redness, skin tearing, bruising or abrasions on her head, neck, chest, abdomen, thighs, legs or perineal region. There was no blood or any type of discharge in the patient's diaper. There is no evidence that we see of any type of injury or forced trauma on this patient. I do not see any physical findings at this time that lead me to believe that the patient has been harmed in any way. Interview on 6/19/19 at 11:05 a.m., with the Acting Assistant Director of Health Services (AADHS) confirmed that she first became aware of the physical contact between R#6 and R#7, that had occurred on 6/8/19, and 6/9/19, after R#6 had re-entered R#7's room on 6/9/19. The AADHS stated that she was working the day shift, on Sunday (6/9/19), on the North hall and overhead a conversation at the nursing station between LPN AA and LPN BB and CNA CC and that she asked them what was going on. When they told her, about the incident that occurred on 6/8/19 and 6/9/19, the AADHS made them aware that the incident should have been reported right away. The AADHS stated that she would not have considered that R#6 and R#7 were having a relationship because R#7 could not consent to a sexual relationship. The AADHS stated that LPN AA should have known that the sexual contact initiated by R#6 was not consensual contact. Although the two LPN's (AA and BB) removed R#6 from R#7's room on 6/8/19, they failed to immediately notify the Administrator. The staff's failure to report this incident resulted in a failure to provide protection for R#7 which resulted in R#6 re-entering R#7's room again on 6/9/19 causing R#7 continued fear. The facility implemented the following interventions to remove the Immediate Jeopardy: 1. Resident #6 was put on one-on-one supervision until he was transferred to another facility on 6/11/19. Resident #6 will not be returning to the facility. On 6/9/19 both LPN's were suspended. LPN #1 (AA) was subsequently terminated for not timely reporting incident. LPN #2 (BB) received education on abuse and timely reporting by the DHS before returning to work on 6/17/19. Resident #7 had a Quarterly Minimum Data Set (MDS) Assessment on 5/4/19 with a Brief Interview for Mental Status (BIMS) score of 6. Resident #7 was assessed by the DHS on 6/9/19 regarding her emotional and physical well-being and sent to the ER for emergency evaluation as well. Resident #7 has been assessed daily for her emotional/behavioral health by the DHS since 6/9/19 and has been added to the Behavior Management Program on 6/10/19. Resident #7 is also scheduled for a behavioral health services check with outside Psychiatrist on 7/10/19. 2. All residents have the potential to be affected. The ADHS, DHS, and Social Worker has completed abuse interviews with cognitive residents that have a BIMS score between 10-15 to rule out any other abuse allegations. Questions included has staff, a resident, or anyone else here abused you and have you seen any resident here being abused? Residents with a BIMS score lower than a 10 will receive a body audit and assessed for any behavioral changes. All interviews and body audits were completed between 6:00 p.m. and 11:00 p.m. on 6/25/19. An interview was conducted with forty-three residents and the remaining twenty-two residents received a body audit for a total of 65 residents in house. No adverse findings were found. 3. All staff were in-serviced by the DHS and Clinical Competency Coordinator (CCC) on abuse, types of abuse, timely abuse reporting, who to report abuse to and when to report abuse; including state agency contact information, resident protection (one-on-one supervision). Scenarios were also provided to staff on abuse identification of abuse indicators with non-cognitive resident to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying, or fear of being alone with staff. In-service education was initiated on 6/25/19 at 7:30 p.m. until 11:00 p.m. and completed 6/26/19 between 9:00 a.m. and 11:00 a.m. 5 of 5 RN's, 12 of 12 LPN's, 21 of 21 CNAs, 8 of 8 housekeeping, 7 of 7 administrative, 6 of 6 dietary, 4 of 4 therapy, and 1 of 1 maintenance 100% of staff have competed in-service on 6/26/19. 4. Newly hired staff will be in-serviced on abuse on the first day of hire during orientation and annually by the CCC. 5. The CCC and/or Social Worker will interview 5 residents a week for 6 weeks on abuse questions and for cognitively impaired residents the DHS and/or ADHS will complete the Weekly Head to Toe Assessment. The CCC will report any adverse findings to the administrator immediately. The Administrator will report adverse findings to the state agencies and the DHS or ADHS will report adverse findings to the physician. The CCC and/or Social Worker will also interview 5 staff members per week for 6 weeks, Monday through Friday on both shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m., on questions about abuse and abuse scenarios. The abuse scenarios will include cognitively impaired residents to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying or fear of being alone with staff. Any adverse findings will be reported to the Administrator immediately for proper reporting to state agency. 6. The immediate jeopardy was communicated with the Senior Nurse Consultant, Area Vice President, Sr. Vice President of Clinical Services, and COO of Community Services on 6/25/19. An ad hoc meeting was held with the medical director, the administrator, DHS, ADHS, Licensed Practical Nurse, senior nurse consultant, area vice president, restorative nurse and certified nursing assistant on 6/27/19 to discuss the immediate jeopardy finding and the allegation of credible compliance. 7. The Administrator will take all findings to the QAPI committee for action as needed monthly beginning 06/26/19 x 3 months. All immediate corrective actions will be completed by 6/27/19. The State Agency Validated the following to remove the Immediate Jeopardy: 1. Record review revealed a Physician order for [REDACTED]. A Physician order dated 6/11/19 for R#6 that documented may transfer to DCH via 1013; Res (Resident) medically stable for transport. Review of a Nurses Note dated 6/11/19 at 2:00 p.m., documented Res transported to psych in-patient facility via 1013 . Record review of a One on One Monitoring form dated 6/9/19 at 8 p.m. revealed the following instructions documented: Staff member is to closely monitor res. If he leaves his room for any reason. Day 1 Sunday Res. Placed on 1:1 monitoring at 8 p.m. d/t (due to) alleged sexual assault. Immediately following incident, resident returned to his room and was monitored by CN[NAME] Night 1 Sun (Sunday): Stayed in bed all night did not leave his room. Day 2 Mon (Monday) 6-10 - Walked in hall for short time, returned to bed and didn't come out of room. Monitored him while out of bed. Night 2 Mon 6-10 Charge nurse monitored resident and was given instruction to observe if resident left room for any reason. I served as Charge Nurse (CN) and he did not leave his room. Day 3 Tuesday 6/11/19 Watched until discharged , walked only in room and returned to bed. Behavioral Symptom Screening Form for R#7 dated 6/9/19, 6/12/19, 6/19/19, 6/26/19, documented the following: Resident was the victim of an alleged sexual assault from another male resident. Resident appeared frightful and scared. Review of the list of residents that had a Brief Interview for Mental Stability (BIMS) of 10 or Greater revealed a list of 43 Residents with BIMS greater than 10. Census list dated 6/25/19 revealed that 43 residents are marked as being interviewed and that 22 residents are documented as having skin assessments. Forty-three resident interviews revealed no adverse findings were noted. Twenty-two skin assessments were completed. Review of the 22 skin assessments revealed that there were not any adverse findings noted. Record review of the Census list documents for each resident document that one on one education was provided to the resident and documented that letter was mailed to the responsible party and the date letter was mailed. 2. Record review revealed that Body Audit forms were completed for each of the 22 residents without any adverse findings noted. Further review revealed 43 Resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided regarding the facility abuse policy. Each form documented that education was provided regarding the facility abuse policy. 3. Record review of the Inservice Education Program Summary Record dated 6/27/19 revealed that the abuse policy and procedure was reviewed. In addition, symptoms of abuse in non-cognitive residents: fearfulness, anger, stress, defensiveness, anxiety, worry or fear of being alone with person. Forty-one staff members are noted to have signed this form. Record review of the Active Employee Listing revealed that the facility has 59 active employees. Fifty-nine employees signed Inservice Education Program Attendance Record Form. Review of the Inservice Education Program Summary Record Form dated 6/25/19 through 6/26/19 revealed that education was provided regarding abuse, what is abuse, types of abuse, any suspected abuse must be reported immediately to the Administrator, no matter what time of day or what time. Abuse scenario reviews. Interview with staff on 6/28/19 revealed that staff had been educated on the components of the abuse policy, and received in-services regarding what is abuse, types of abuse, signs of symptoms of abuse for cognitively impaired residents, who to report abuse to, when to report abuse, and how to report abuse. Interviews included the following staff and residents: LPN FF ( 6/28/19 at 11:00; CNA GG- 1:41 p.m.; at 11:49 a.m. Financial Counselor HH; 12:08 p.m. Speech language Pathologist II; at 12:51 p.m. with Floor Tech JJ; at 1:10 p.m. with CNA KK and CNA LL; at 1:16 p.m. with the DON; at 1:30 p.m. with HK (QQ); at 1:34 p.m. Maintenance & Housekeeper MM; at 1:37 p.m. Laundry Aide NN; at 1:40 p.m. with PTA OO; at 1:47 p.m. LPN Unit Manager PP; at 1:40 p.m. with HK RR; at 1:50 p.m. LPN SS (7A-7P) (SS); at 2:00 p.m. with Dietary TT; at 2:30 p.m. with Dietary UU; at 4:57 p.m. with Area Vice President, Senior Nurse Consultant, the DHS, and ADHS; at 3:55 pm- CNA VV (7P-7A); 6/28/19 at 4:10 p.m. with LPN WW (7P-7A); at 4:30 p.m. with LPN XX (7P-7A); 6/28/19 at 5:00 p.m. RE. Interview on 6/28/19 at 3:05 p.m. via telephone with a family member of resident C stated the SW called him on 6/27/19 to talk about abuse and the policy. She told him they would be mailing him a copy of the policy and was to sign the form and mail it back. Interview on 6/28/19 at 4:40 p.m. with R D stated the staff gave her a copy of the abuse policy and procedure yesterday and talked to her about abuse and the policy. R D stated the staff also gave her roommate a copy. Interview on 6/28/19 at 5:00 p.m. with R [NAME] stated she had a copy of the abuse policy which was sitting on her overbed table that they brought her yesterday. 4. Record review revealed the facility had two new employees. Interview with LPN FF on 6/28/19 at 11:00 a.m. revealed that her first day was Wednesday and that she had received the following training: Abuse training - types of abuse physical, verbal, mental, sexual; right not to be abused, report, report immediately within two hours. If you see, remove abuser immediately - and contact DHS and Administrator. Check on the abused monitor for fear, anxiety, can't talk - tense, flinching. Received on the first day and every day since then. I immediately report to Administrator or DHS. Phone numbers are on bulletins. Beside Abuse policy. I know how to get abuse policy. A copy of policy is posted. Always report. Person is safe. Even if resident is confused you treat as any allegation of abuse and you report immediately. Protect resident. Separate the residents and watch perpetrator. Protection is priority. Delegate staff members. 5. Record review revealed that The Clinical Care Coordinator (CCC) and Social Worker (SW) interviewed five residents for the week of 6/27/19 regarding abuse and five additional Head to Toe assessments were completed for cognitively impaired residents. No adverse findings were noted. Further review revealed five Staff Abuse Questionnaires that included the following questions: What training have you received at this facility regarding abuse and neglect? How often is training held, what would you do if a resident becomes agitated and physically aggressive while you were providing care? Per our policy who would you report alleged abused to? List two examples of abuse, what would you do if you discovered two residents fighting? What would you do if you saw a staff member hit a resident? What would you do if the staff member you saw hit a resident was back at work the next day performing care to the residents? Do you know where the numbers are to report abuse and neglect? Can you tell me per our abuse policy, how quickly does the facility have to report alleged abuse to the state? 6. Review of the Ad hoc QAPI meeting notes revealed an Ad hoc meeting was held on 6/27/19 at 3:00 p.m. and that the following were in attendance: Physician, three LPN's, one RN, Administrator, Area Vice President, Senior Nurse Consultant, one CNA and topics discussed were ongoing complaint survey/IJ tags. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that an Ad hoc QAPI meeting was held 6/27/19 to discuss the findings with the Immediate Jeopardy tags. 7. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that the findings for the Immediate Jeopardy will be taken to the QAPI committee for action as needed. | 2020-09-01 |
| 2969 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 607 | J | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review, review of written statements, review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation and review of the facility policy titled Abuse Prevention and Reporting and review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property it was determined that the facility failed to implement the protection and reporting component of their abuse policy when two LPN's failed to report an incident of sexual abuse for one of 14 residents (R#7) reviewed for abuse and the facility failed to provide protection for one of one residents ( R#7) after an allegation of sexual abuse was made on (MONTH) 8, 2019. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately reported the incident to two Licensed Practical Nurses (LPN). However, the LPN's failed to immediately report the incident to Administration which lead to a failure to protect R#7 resulting in R#6 re-entering her room again on (MONTH) 9, 2019 which caused R#7 continued fear. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600), Scope/Severity: J and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607), Scope/Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at 483.12(a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607, Scope/Severity: J). A Removal Plan was received on (MONTH) 26, 2019 related to 42 C.F.R. 483.12(a)(1), Free from Abuse and Neglect (F600) and 42 C.F.R. 483.12(a)(1), Develop/Implement Abuse/Neglect Policies (F607). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans was implemented therefore, the immediacy of the deficient practice was removed on (MONTH) 28, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of ensuring that staff and residents are educated on the facility's abuse policy and know what abuse is, when to report abuse, and how to report abuse. This oversight process included the analysis of the facility staffs' conformance with the facility's abuse policies and procedures governing the timely and accurate reporting of abuse and implementing interventions in their abuse policy. In-service materials and records were reviewed. Observations and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility policies and procedures regarding what is abuse and when and how to report abuse. Findings include: A review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the definition of sexual abuse is non-consensual sexual contact of any type with a patient. A review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property documented the following procedure: Any allegation, suspicious, or identified occurrence involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. A review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property documented the following procedure under the section titled Protection: During an active investigation of patient abuse, neglect, exploitation, mistreatment or misappropriation of patient property, when there is substantial evidence that such has occurred, the provider should take all reasonable efforts to protect the affected patient(s) from harm. R#6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 5/15/19, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident was also assessed as requiring minimal assistance from staff. The resident was independent for locomotion on and off the unit and utilized a wheelchair and walker for mobility. R#7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R#7 was assessed by the facility on the 5/4/19, MDS as having a BIMS score of six indicating that the resident was severely cognitively impaired with decision making skills and demonstrated inattention. The resident required extensive assistance of one person for bed mobility and was nonambulatory. She was totally dependent on staff for dressing, hygiene and bathing. She was assessed as having functional limitation in range of motion of the upper extremity on one side and impairment on both sides of the lower extremities. During an interview with Licensed Practical Nurse (LPN BB), (a.m.- 7 p.m. shift) on 6/18/19 at 4:08 p.m., revealed that on Saturday, 6/8/19, after 7:00 p.m., a CNA came and reported to LPN AA that R#6 was kissing R#7 on her face and that he had his hand under the covers. LPN BB stated she and the other nurse, LPN AA, went down to R#7's room and asked R#6 to leave. LPN BB stated that R#6 got mad and called them racists. Further interview with LPN BB revealed that on 6/9/19 around shift change she was walking by R#7's room and her eyes met R#7's eyes. LPN BB stated that R#7 looked fearful. LPN BB stated that she saw R#6 was in the room talking to R#7's roommate and then R#6 went over to R#7's bed. LPN BB stated that R#7 continued to have a fearful look on her face. LPN BB went into the room and asked R#7 if she wanted R#6 in her room and R#7 responded, no. LPN BB stated she then asked R#6 to leave, and that R#6 got mad and left. Continued interview with LPN BB revealed that on 6/9/19 she told the Acting Assistant Director of Health Service (AADHS) that R#6 had been in R#7's room twice and that R#7 was fearful. After that, CNA DD told the AADHS what occurred on 6/8/19, when they saw R#6 in R#7's room kissing her on the face with his hand under the covers. LPN BB stated that the AADHS said Oh my God, that has to be reported. During an interview on 6/19/19 at 11:05 a.m., the Acting Assistant Director of Health Services (AADHS) confirmed that she first became aware of the physical contact between R#6 and R#7 on 6/9/19, after R#6 had re-entered R#7's room on 6/9/19. When they told her what occurred on 6/8/19 and 6/9/19, she made them aware that the incident should have been reported right away. During an interview with LPN SS on 6/19/19 at 11:05 a.m., she stated she had been off work when all of this happened. She stated she returned to work on 6/10/19, and was assigned to the floor that R#7 resided on but no one informed her of the incident until after R#6 left the faciity on [DATE]. LPN SS also stated nobody told her to watch to ensure that R#6 did not go near R#7. During a telephone interview with LPN AA (p.m.-a.m. shift) on 6/19/19 at 11:35 a.m., she stated that she was taking report with the day shift nurse on 6/8/19 around 8:00 p.m., when the CNA's came to her and said R#6 had his hands under R#7's covers. When she and LPN BB went to the room she asked R#6 to leave the room. R#7 told her that he touched her, but she did not specify where. She stated she examined R#7 and noticed her brief was on tight and there was no redness or swelling. She also stated that R#6 was in R#7's room morning, noon and night but she never saw any behaviors prior to this. She stated she did not report this to anyone because she thought the residents were boyfriend and girlfriend. LPN AA stated the next night, 6/9/19, when she came on duty LPN BB told her R#6 had been in R#7's room again and she made him leave. LPN BB said she did not call the physician on 6/8/19. LPN AA further stated that LPN BB told her when she worked on 6/9/19 that there were no special instructions given to them to start one-on-one monitoring with R#6 or to keep R#6 out of R#7's room. During an interview with the Administrator and the Director of Health Services (DHS) on 6/20/19 at 9:50 a.m., they stated that light duty CNA's were on the hall watching R#6 and would shadow the resident if he came out of his room. They stated one of the light duty CNAs would have been assigned to watch the resident. Further interview revealed that the Administrator and DHS were unable to show the surveyor on the actual assignment sheets for 6/9/19, 6/10/19 and 6/11/19 who was assigned to watch R#6. During an interview with LPN EE on 6/26/19 at 10:45 a.m., she stated that there were no light duty CNAs working the night shift (7 p.m.-7 a.m.) on 6/9/19, or on 6/10/19, and stated that there were no staff actually assigned to stand in the hallway and watch R#6. LPN EE stated staff would just note where the resident was as they were out doing their assignments. Review of the Pruitt Health Daily Nursing Assignment Form revealed the following: On 6/8/19 the 7 p.m.-7 a.m., shift had two LPN's and three CNA's working with assignments. On 6/9/19 the 7 a.m.-7 p.m., shift had two LPN's and four CNA's with one light duty CNA who made beds, answered call lights and assisted with meals. The 7 p.m.-7 a.m., shift had two LPN's and three CNA's with no light duty staff scheduled. All the staff had assignments. On 6/10/19 the 7 a.m.-7 p.m., shift had two LPN's, four CNA's who had assignments and one CNA in training who also had an assignment. There were two light duty CNA's who were either assigned to the hydration cart and to accompany residents to appointments on transport. The 7 p.m.-7 a.m., shift had two LPN's and five CNA's who all had an assignment. On 6/11/19 the 7 a.m.-7 p.m., shift had two LPN's and five CNA's who had assignments and two light duty CNA's who either were assigned hydration or to accompany residents to appointments on transport. During an interview and review of the assignment forms with the AADHS on 6/26/19 at 10:45 a.m., she stated she was responsible for making out the assignment sheets. In reviewing the assignment sheets, she stated there were no light duty CNA's scheduled on 6/8/19 on the 7 p.m.-7 a.m., shift. She stated on 6/9/19, there was only one light duty staff who worked from 7 a.m.-3 p.m., making beds, answering call lights and assisting with meals. She stated there were no light duty staff on the 7 p.m.-7 a.m., shift and all of the staff had an assignment. She stated on 6/10/19 a.m.-p.m., there were three light duty CNA's. One was assigned hydration who worked from 8:00 a.m.- 4:30 p.m. passing out ice, water and snacks, another CNA was on transport and the third CNA worked from 7:00 a.m. -3:00 p.m., with another CNA who had an assignment. She stated the 7:00 p.m. - 7 a.m. shift did not have light duty staff and all the staff had assignments that night. She stated on 6/11/19, 7 a.m.- 7 p.m., had two light duty CNA's. One was on transport and the other on hydration from 8:00 a.m. - 4:30 p.m. Although the facility indicated R#6 was put on one-on-one observation there was no evidence that the facility called in additional staff to provide this supervision, and there was no evidence that the facility had light duty CNA's scheduled for the 7 p.m. - 7 a.m., shift. from 6/8/19 through 6/11/19, when R#6 was transferred to a psychiatric hospital. The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #6 was put on one-on-one supervision until he was transferred to another facility on 6/11/19. Resident #6 will not be returning to the facility. On 6/9/19 both LPN's were suspended. LPN #1(AA) was subsequently terminated for not timely reporting incident. LPN #2 (BB) received education on abuse and timely reporting by the DHS before returning to work on 6/17/19. Resident #7 had a quarterly Minimum Data Set (MDS) Assessment on 5/4/19 resulting in a Brief Interview for Mental Status (BIMS) score of 6. Resident #7 was assessed by the DHS on 6/9/19 regarding her emotional and physical well-being and sent to the ER for emergency evaluation as well with no reported negative outcome. Resident #7 has been assessed daily for her emotional/behavioral health by the DHS since 6/9/19 and has been added to our Behavior Management Program on 6/9/19 and reviewed weekly. Resident #7 is also scheduled for a behavioral health services check with an outside Psychiatrist on 7/10/19. 2. The abuse policy was reviewed by corporate on 1/8/19 and then again by the Area Vice President and Administrator on 6/25/19. Our review of the policy determined the policy was in good standing and well developed and included the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse (2-hour timeline). 3. All residents have the potential to be affected. The ADHS, DHS, and Social Worker completed interviews regarding our facility abuse policy with cognitive residents that have a BIMS score between 10-15 to rule out any questions or concerns. Questions include do you have any questions on our abuse policy? and per policy do you know who to report to if you or someone has been abused in our facility? All interviews were completed between 10:00 a.m. and 1:00 p.m. on 6/27/19 with no adverse findings reported. 4. At the time of the interviews all forty-three cognitive residents were educated on the facility abuse policy including the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse. On 6/27/19 all forty-three cognitive residents received a copy of the abuse policy. The families, responsible parties, and/or power of attorneys, of the twenty-two residents with a BIMS lower than 10 were mailed the abuse policy on 6/27/19. 5. All staff was in-serviced by the DHS and Clinical Competency Coordinator (CCC) on our abuse policy and the seven components; abuse identification, types of abuse, right to be free of abuse, investigating abuse, prevention of abuse, protecting against abuse, and reporting of abuse. Scenarios were also provided to staff on abuse identification of abuse indicators with non-cognitive residents to observe for fearfulness, anger, stress, defensiveness, anxiety, worrying, or fear of being alone with staff. In-service education was initiated on 6/25/19 at 7:30 p.m. until 11:00 p.m. and completed 6/26/19 between 9:00 a.m. and 11:00 a.m. 5 of 5 RN's, 12 of 12 LPN's, 21 of 21 CNAs, 8 of 8 housekeeping, 7 of 7 administrative, 6 of 6 dietary, 4 of 4 therapy, and 1 of 1 maintenance have all been in-serviced. 100% of staff was competed on 6/26/19. A copy of the abuse policy was posted on the bulletin board located at the front entrance and by the therapy department for all visitors and staff members to have for review. A list of names and contact numbers of the Administrator, DHS, and CCC were also posted. 6. Newly hired staff will be in-serviced on the abuse policy on the first day of hire during orientation and annually by the CCC. 7. The CCC and/or Social Worker will interview 5 residents a week, for 6 weeks on the above-mentioned abuse policy questions starting 6/27/19. The CCC will report any adverse findings to the administrator immediately. The Administrator will report adverse findings to the state agencies, Ombudsman at (phone number), and the Facility Regulation Division at (phone number). The DHS or ADHS will also report adverse findings to the physician and/or Medical Director. The CCC and/or Social Worker will also interview 5 staff members per week, Monday through Friday on both shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m., for 6 weeks. The interview questions are on our abuse policy to make sure staff is familiar with our abuse policy. Adverse findings will be reported to the Administrator immediately for proper reporting to state agency. 8. The immediate jeopardy was communicated with the Senior Nurse Consultant, Area Vice President, Senior Vice President of Clinical Services, and COO of Community Services on 6/25/19 4:40 p.m. An Ad hock meeting was held with the medical director, the administrator, DHS, ADHS, Licensed Practical Nurse, senior nurse consultant, area vice president, restorative nurse and certified nursing assistant on 6/27/2019 to discuss the immediate jeopardy finding and the allegation of credible compliance. 9. The Administrator will take all findings to the QAPI committee for action as needed monthly beginning 06/26/19, times 3 months. 10. All immediate corrective actions will be completed by 6/27/19. The State Agency validated the following to remove the Immediate Jeopardy: 1. Record review revealed a Physician order for [REDACTED]. A Physician order dated 6/11/19 for R#6 that documented may transfer to DCH via 1013; Res (Resident) medically stable for transport. Review of a Nurses Note dated 6/11/19 at 2:00 p.m., documented Resident transported to psych in-patient facility via 1013. Record review of a One on One Monitoring form dated 6/9/19 at 8 p.m., revealed the following instructions documented: Staff member is to closely monitor res. If he leaves his room for any reason. Day 1 Sunday Res. Placed on 1:1 monitoring at 8 p.m., d/t (due to) alleged sexual assault. Immediately following incident, resident returned to his room and was monitored by CN[NAME] Night 1 Sun (Sunday): Stayed in bed all night did not leave his room. Day 2 Mon (Monday) 6-10 - Walked in hall for short time, returned to bed and didn't come out of room. Monitored him while out of bed. Night 2 Mon 6-10 Charge nurse monitored resident and was given instruction to observe if resident left room for any reason. I served as Charge Nurse (CN) and he did not leave his room. Day 3 Tuesday 6/11/19 Watched until discharged , walked only in room and returned to bed. Behavioral Symptom Screening Form for R#7 dated 6/9/19, 6/12/19, 6/19/19, 6/26/19, documented the following: Resident was the victim of an alleged sexual assault from another male resident. Resident appeared frightful and scared. 2. Record Review of the facility's abuse policy revealed that it was last revised 1/8/19 the policy includes the seven components including: screening, training, prevention, identification, investigation, protection, reporting and response to abuse. The policy addresses misappropriation of property, exploitation, mistreatment, mistreatment and misappropriation of property. Investigating abuse, No retaliation, prevention of abuse, reporting. 3. Review of the Census list dated 6/25/19 revealed that 43 residents are marked as being interviewed and that 22 residents are documented as having skin assessments. Record review revealed that Body Audit forms were completed for each of the 22 residents without any adverse findings noted. Further review revealed 43 Resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided regarding the facility abuse policy. Interview on 6/28/19 at 3:05 p.m., via telephone with a family member of resident C stated the Social Worker (SW) called him on 6/27/19 to talk about abuse and the policy. She told him they would be mailing him a copy of the policy and was to sign the form and mail it back. Interview on 6/28/19 at 4:40 pm with R D stated the staff gave her a copy of the abuse policy and procedure yesterday and talked to her about abuse and the policy. R D stated the staff also gave her roommate a copy. Interview on 6/28/19 at 5:00 pm with R [NAME] stated she had a copy of the abuse policy which was sitting on her overbed table that they brought her yesterday. 4. Record review revealed 43 resident interviews regarding Abuse. Specific questions included: Has staff, a resident, or anyone else here abused you? Have you seen any resident here being abused? Each form documents that each of the 43 residents received education on how to report suspected abuse/neglect. There were no negative findings of abuse noted. Each form documented that education was provided to each resident regarding the facility abuse policy. Record review of the Census list revealed letters were mailed, on 6/27/19, to Family Members and/or Responsible Party, that the facility would like to ensure our family members, responsible parties, and residents are aware of our Abuse Policy & Procedure that details the types of abuse, who to report abuse to, time to report, investigation, possible staff disciplinary actions, protection of resident, facility will investigate all allegation of abuse. The letter also documents that the facility will be having a Family Council meeting on 7/10/19 to further discuss abuse policies. Record review of the Census list documents for each resident documented that one on one education was provided to the resident and documents that letters were mailed to the responsible party and the date the letters were mailed (6/27/19). 5. Record review of the Inservice Education Program Summary Record dated 6/27/19 revealed that the abuse policy and procedure was reviewed. In addition, symptoms of abuse in non-cognitive residents: fearfulness, anger, stress, defensiveness, anxiety, worry or fear of being alone with person. Forty-one staff members are noted to have signed this form. Record review of the Active Employee Listing revealed that the facility has 59 active employees. Fifty-nine employees signed Inservice Education Program Attendance Record Form. Review of the Inservice Education Program Summary Record Form dated 6/25/19 through 6/26/19 revealed that education was provided regarding abuse, what is abuse, types of abuse, any suspected abuse must be reported immediately to the Administrator, no matter what time of day or what time. Abuse scenario reviews. Interview with staff on 6/28/19 revealed that staff had been educated on the components of the abuse policy, and received in-services regarding what is abuse, types of abuse, signs of symptoms of abuse for cognitively impaired residents, who to report abuse to, when to report abuse, and how to report abuse. Interviews included the following staff and residents: LPN FF ( 6/28/19 at 11:00; CNA GG- 1:41 p.m.; at 11:49 a.m. Financial Counselor HH; 12:08 p.m. Speech language Pathologist II; at 12:51 p.m. with Floor Tech JJ; at 1:10 p.m. with CNA KK and CNA LL; at 1:16 p.m. with the DHS; at 1:30 p.m. with HK (QQ); at 1:34 p.m. Maintenance & Housekeeper MM; at 1:37 p.m. Laundry Aide NN; at 1:40 p.m. with PTA OO; at 1:47 p.m. LPN Unit Manager PP; at 1:40 p.m. with HK RR; at 1:50 p.m. LPN SS (7A-7P) (SS); at 2:00 p.m. with Dietary TT; at 2:30 p.m. with Dietary UU; at 3:05 p.m. via telephone with, son of resident C; at 4:40 p.m. with RD; at 4:57 p.m. with Area Vice President, Senior Nurse Consultant, the DHS, and ADHS; at 3:55 pm- CNA VV (7P-7A); 6/28/19 at 4:10 p.m. with LPN WW (7P-7A); at 4:30 p.m. with LPN XX (7P-7A); 6/28/19 at 5:00 p.m. RE. 6. Record review revealed the facility had two new employees. Interview with LPN FF on 6/28/19 at 11:00 a.m., revealed that her first day was Wednesday and that she had received the following training: Abuse training - types of abuse physical, verbal, mental, sexual; right not to be abused, report, report immediately within two hours. If you see, remove abuser immediately - and contact DHS and Administrator. Check on the abused monitor for fear, anxiety, can't talk - tense, flinching. Received on the first day and every day since then. I immediately report to Administrator or DHS. Phone numbers are on bulletins. Besides Abuse policy. I know how to get abuse policy. A copy of policy is posted. Always report. Person is safe. Even if resident is confused you treat as any allegation of abuse and you report immediately. Protect resident. Separate the residents and watch perpetrator. Protection is priority. Delegate staff members. 7. Record review revealed that The Clinical Care Coordinator (CCC) and Social Worker (SW) interviewed five residents for the week of 6/27/19 regarding abuse and five additional Head to Toe assessments were completed for cognitively impaired residents. No adverse findings were noted. Further review revealed five Staff Abuse Questionnaires that included the following questions: What training have you received at this facility regarding abuse and neglect? How often is training held, what would you do if a resident becomes agitated and physically aggressive while you were providing care? Per our policy who would you report alleged abused to? List two examples of abuse, what would you do if you discovered two residents fighting? What would you do if you saw a staff member hit a resident? What would you do if the staff member you saw hit a resident was back at work the next day performing care to the residents? Do you know where the numbers are to report abuse and neglect? Can you tell me per our abuse policy, how quickly does the facility have to report alleged abuse to the state? 8. Review of the Ad hoc QAPI meeting notes revealed an Ad hoc meeting was held on 6/27/19 at 3:00 p.m., and that the following were in attendance: Physician, three LPN's, one RN, Administrator, Area Vice President, Senior Nurse Consultant, one CNA and topics discussed were ongoing complaint survey/IJ tags. Interview on 6/28/19 at 1:47 p.m., with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that an Ad hoc QAPI meeting was held 6/27/19 to discuss the findings with the Immediate Jeopardy tags. 9. Interview on 6/28/19 at 1:47 p.m. with the Area Vice President, Senior Nurse Consultant, Director of Health Services, and Assistant Director of Health Services revealed that the findings for the Immediate Jeopardy will be taken to the QAPI committee for action as needed. | 2020-09-01 |
| 344 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-11-14 | 658 | D | 1 | 0 | VEPN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observations, record review, review of facility policy titled Medication Administration and review of the Georgia Nurse Practice Act (chapter 410-10), the facility failed to provide supervision with the administration of medications for one of five sampled residents (R) (#10). Findings include: The Practice of Nursing includes, but is not limited to, provision of nursing care; administration, supervision, evaluation, or any combination thereof, of nursing practice; teaching; counseling; the administration of medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title. Guideline #20 of the facility's Administering Medications General Guidelines policy documented the resident is always observed after administration to ensure that the dose was completely ingested. Review of the clinical record revealed R#10 has [DIAGNOSES REDACTED]. R#10 is his own responsible party. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. A Physician's Note dated 10/15/19 revealed R#10 with intermittent confusion, staff documented that he gets belligerent and aggressive at times. He is a bit demanding about his medications. During an interview on 10/29/19 at 7:30 a.m., R#10 revealed Licensed Practical Nurse (LPN) QQ gave him all his morning medication at 6:00 a.m. He then opened the drawer to his bedside table and produced a clear dosage cup, containing 10 pills. R#10 stated LPN QQ left the pills for him to take later. During an interview on 10/29/19 at 7:42 a.m., LPN QQ stated R#10 is medication seeking and she did not leave any pills with him. LPN QQ went to R#10's room and R#10 stated he had taken the pills because he didn't want anyone to take them from him. He then reached underneath his bed covers and produced the cup of medication. He also reached into the cup, removed and ingested one white, round pill that he stated was Klonopin. During continued interview on 10/29/19 at 7:42 a.m., LPN QQ stated if you don't start with his medications immediately on your med pass, he will make you miserable. He can get all the medications he was given at once. I gave him his 6:00 a.m. meds about 5:00 a.m. because he was asking for them. He was right in front of me with the water. I thought he took it. I was supposed to watch the resident take the medicine, but I didn't. He was pressing me to give him his medication. I gave it to him and left. I should have waited for him to take it. I was busy with a [MEDICAL TREATMENT] patient; the transportation was rushing me. The Certified Nursing Assistant was helping me but, there was a lot going on. During an interview on 10/29/19 at 8:16 a.m., Unit Manager (UM) AA revealed R#10 is very meticulous about his medications. UM AA was unaware of any pills in his nightstand drawer. UM AA stated that residents are not allowed to keep medications in their rooms. The nurse has to make sure they take the medications before leaving the room. R#10 can safely have his morning medications all at once but, he has to take them. The nurse should not have just left them with him. No matter how alert a resident is, it's against facility policy. During further interview on 11/4/19 11:14 a.m., UM AA revealed that R#10 does not have physician orders [REDACTED]. During an observation on 10/29/19: 7:57 a.m., with LPN QQ, a comparison was made with the remaining medications in the dosage cup and R#10's ordered medications in the medication cart. The following medications were identified: [MEDICATION NAME] 30 milligram (mg) Losartan Potassium 100mg [MEDICATION NAME] 5mg [MEDICATION NAME] ER 30 [MEDICATION NAME] 7.5mg [MEDICATION NAME] 25mg Vitamin C OTC (over the counter) Aspirin 81 mg [MEDICATION NAME] tablet 75mg During further interview on 10/29/19 at 8:35 a.m., R#10 revealed that he took the [MEDICATION NAME] pill and pain meds at the cart along with the muscle relaxers. LPN QQ asked him if he wanted the rest of his morning pills. He said yes, she gave it to him, and he walked away with the cup. R#10 stated that he usually gets his pills, goes to his room, makes sure they are all there, and then takes them. Some of the nurses just set them down, turn around and walk out. During an interview on 10/30/19 at 4:07 p.m., the Medical Director (MD) revealed, it is not the facility's operation that a nurse leaves medication with a resident. | 2020-09-01 |
| 3267 | PARKSIDE POST ACUTE AND REHABILITATION | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2018-05-20 | 658 | D | 1 | 0 | 9RIX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and observation it was determined that the facility failed to record the vital signs more than three times in a six-month period for one Resident (R#5) out of three residents reviewed. R#5 [DIAGNOSES REDACTED].) Findings include: Resident (R) #5 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. R#5's medications included [MEDICATION NAME] (anxiety), [MEDICATION NAME] (depression), and [MEDICATION NAME] (high blood pressure). Review of R#5's most recent assessment (quarterly )Minimum Data Set (MDS) assessment dated [DATE] revealed the that the resident is cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Per the quarterly MDS, the resident was coded in Section I 0700 [DIAGNOSES REDACTED]. The MDS (quarterly) dated 1/12/18 prior to hospitalization revealed the same coding. Review of acute hospital critical care progress note, dated 4/8/18, revealed R#5 was admitted to the Intensive Care Unit (ICU) on 4/6/18. The note further revealed the physician diagnosed shock secondary to hypovolemia (low blood volume), septic shock, and acute kidney injury related to low blood pressure. R#5 returned to the facility on [DATE]. On 5/2/18 at 11:15 a.m. Family of R#5 was interviewed over the telephone. She stated she was R#5's daughter. She stated R#5 had been doing well until on or about 4/6/18 when she was called by the facility and told R#5 was going to the hospital. She stated she went to the facility to find out what was going on and was told her mother's blood pressure had dropped. She stated she asked to see R#5's vital sign record and was shown the record in the computer. She stated there was no record for vital signs in the computer between 9/2017 and 4/2018. Review of the blood pressure summary in the facility electronic medical record (EMR), reveals no record of vital signs between 9/18/17 and 4/6/18. A review of the R#5's paper chart revealed no information on vital signs, except on 1/10/18, 2/27/18, and 4/12/18, all on psychiatric progress notes. Review of R#5's care plan, reviewed by facility staff on 2/5/18, planning for hypertension (high blood pressure). The plan goal was the resident would maintain normal vital signs and a decrease on signs/symptoms of hypertension. Interventions included the monitoring for side effects such as orthostatic [MEDICAL CONDITION] (low blood pressure). On 5/2/18 at 11:40 a.m. the Director of Nursing (DON) was interviewed in the classroom. She stated she could not produce further records for R#5's vital signs. She stated no vital signs had been taken between 9/18/17 and 4/6/18 because they did not have a doctor's order to do so and the resident was stable. She stated further she did not think this was insufficient because she did not take her own blood pressure all the time. She also stated the facility did not have a policy on routine vital signs. On 5/2/18 at 1:00 p.m. a telephone interview was conducted with Nurse Practitioner EE. He stated he would expect any resident with high blood pressure should have their blood pressure and other vital signs taken every day and that would be his expectation. On 5/2/18 at 1:15 p.m. R#5 was interviewed in her room. She was in her bed and had just finished lunch. When asked about her blood pressure monitoring prior to hospitalization she stated no one had taken her blood pressure between last fall and when she went to the hospital. On 5/2/18 at 3:43 p.m. a telephone interview was conducted with the Medical Director. He stated that the standard of care for any resident without co-morbidities on a blood pressure medication would be to check the blood pressure every three days at the very least. He stated further it was unacceptable that a blood pressure would not be checked for several months. He stated further if a resident had multiple diagnoses, or co-morbidities, the blood pressure should be checked at least once a day, as part of a complete set of vital signs. He also stated a physical exam would be incomplete without obtaining or reviewing a complete set of vital signs. | 2020-09-01 |