Colquitt Regional Senior Care & Rehabilitation

Inspectors wroteBased on record review, resident interview, and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of three residents (R) (R1), who received electrical stimulation (E-STIM) Therapy. Specifically, the facility failed to adequately monitor R1 during active E-STIM treatment to her lower extremities. The deficient practice resulted in R1 sustaining a burn injury to her lower left extremity.

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to ensure residents were informed of the benefits, risks, and alternatives of treatment prior to initiating or increasing psychotropic medication for two of five residents (R) (R2 and R9) of five residents reviewed for unnecessary medications. This deficient practice had the potential for residents to receive medications without knowing the benefits, risks and treatment options.

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed for the Food Service Supervisor (FSS). The deficient practice could result in a staff with an unknown criminal background having access to residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure professional standards were followed for one resident (R) (R50) of 17 sampled residents. Specifically, R50 received nonsteroidal anti-inflammatory drugs (NSAIDs) with a physician's order to avoid NSAID use. This deficient practice placed R50 at risk of adverse clinical outcomes.

Inspectors wroteBased on observation, interview, and review of facility policies, the facility failed to ensure staff followed standard infection control practices during wound care and Enhanced Barrier Precautions (EBP) for two of seventeen residents (R) (R9 and R12) reviewed for infection control practices. These deficient practices have the potential to place residents and staff at risk for cross-contamination and the spread of infections.

Inspectors wroteBased on interview, review of facility documentation, and review of the facility's policy titled, Antibiotic Stewardship, the facility failed to develop an effective Antibiotic Stewardship Program (ASP) to monitor antibiotic use. Specifically, the facility failed to ensure that residents were not prescribed an antibiotic, or were not administered an antibiotic(s), without diagnostic testing that identified an organism and documented symptomology to support the continued use of an antibiotic. This deficient practice has the potential to affect all residents in the facility. Facility census was 54 residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy titled, Transfer or Discharge documentation, the facility failed to ensure a written transfer/discharge notice with required content was provided prior to being transferred for three residents (R), R32, R1, R8, and the resident representatives (RR). In addition, the facility failed to provide the State LTC (Long Term Care) Ombudsman office with notification of residents who transferred or discharged . The deficient practice had the potential for residents to be inappropriately transferred or discharged by not being informed of their rights and appeal options. The sample size was 22 residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy titled, Antipsychotic Medication Use, the facility failed to implement a care plan for monitoring the use of psychotropic medications for two of two residents (R) R154 and R31 reviewed for psychotropic medications. This failure could result in unwarranted use of psychotropic medications and unmanaged medication side effects. The sample size was 22 residents.

Inspectors wroteBased on staff interview and record review, the facility failed to document discharge needs and assessment of a resident being discharged home for one of three residents (R) R44 out of 22 sampled residents. The result of this failure was incomplete documentation and communication among staff in the discharge process of R44.

Inspectors wroteBased on staff interview, record review, review of the dialysis contract, and review of the facility's policy titled, End-Stage Renal Disease, Care of the Resident with, the facility failed to completely document care of a dialysis resident and failed to collaborate with the dialysis center for one of one resident (R) R9 out of 22 sampled residents. This failure resulted in a lack of documentation in the medical record and communication of all staff involved in the care of R9.

Inspectors wroteBased on observation, interview, and review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 54 residents. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents. The sample size was 22 residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Change in a Resident's Condition or Status the facility failed to notify the responsible party and the physician of a change in condition for two residents (R) R#4 and R#9) of 16 residents reviewed.

Inspectors wroteBased on record review and staff interview, the facility failed to document the duration of therapy for one resident (R) R#57) that had an order for PRN [as needed] antianxiety medication beyond 14 days of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and review of policy titled, Hand Hygiene, the facility failed to implement consistent infection control practices during medication administration for four residents (R) R#58, R#10, R#24, and R#26). This omission had the potential to affect any resident receiving medications at the facility. The census was 53. Findings Include: Review of policy titled Hand Hygiene (dated [DATE]) revealed Policy interpretation and Implementation 1. All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2. Associates must perform appropriate handwashing procedures under the following conditions: a. When coming on duty; d. Before preparing or handling medications; g. After contact with blood, body fluids, excretions, secretions, mucous membranes or non-intact skin; and j. [...]