Presbyterian Village - Athens

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan, for one resident (R) (R4) reviewed for pain management. Actual Harm was identified on 9/16/2024 when Podiatrist GG failed to stop and assess R4 yelling out in pain while receiving Podiatry care and treatment. The sample size was 9.

Inspectors wroteBased on record review, review of the Plan of Correction (POC), staff interviews, and review of the policy titled Care Plans - Comprehensive, the facility failed to follow the plan of care for three of three sampled residents (R) (R1, R2, and R22) related to monitoring and recording meal intake.

Inspectors wroteBased on observation, record review, interview, and review of the policy titled Skilled Nursing Facility Resident Rights and Podiatry Policy, the facility failed to ensure the Podiatrist provided care in a dignified manner for one resident (R) (R4), while providing foot care, including cutting toenails and evacuation of left great toe subungual hematoma (collection of blood and clot between the nail bed and the nail plate in the fingers or toes), in a common day area with other residents in the common area. The sample size was 9.

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled Reporting Resident Abuse, Neglect, and Exploitation, the facility failed to provide a complete and thorough investigation of an allegation of abuse for one resident (R) (R13) reviewed for abuse. The sample size was nine.

Inspectors wroteBased on record review, review of the Plan of Correction (POC), interviews, and review of the document titled Bed Hold Letter, the facility failed to provide evidence that notice of the bed-hold policy and return was provided to the resident or residents' representative, upon transfer to the hospital for one of three sampled residents (R) (R6). This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents discharged emergently to the hospital.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow the Physician Orders to offer snacks between meals, for one of three sampled residents (R) (R1).

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Medication Management, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications are given as ordered by the physician. A total of 25 medication opportunities were observed, with two errors, for two of six residents (R) R5 and R16, for a medication error rate of 8%.

Inspectors wroteBased on observation, staff interviews, and review of the policy titled Infection Prevention and Control Program, the facility failed to ensure staff one of two nurses observed practiced acceptable infection control practices to prevent possible cross-contamination as evidenced by not performing hand hygiene during medication administration for three of six residents (R) (R5, R3 and R16). The deficient practice had the potential to increase the possibility of cross contamination.

Inspectors wroteBased on record review, staff interviews, review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers, and review of job descriptions, the facility failed to provide pharmaceutical services that dispensed the correct dosage of physician ordered medication for one of twenty sampled residents (R) (R77). R77 was administered an incorrect dosage of lamotrigine (medication for seizures) for 13 days before a medication error was recognized. Harm was identified to have occurred on 7/15/2024 when R77 experienced a grand mal seizure due to receiving a subtherapeutic dose of lamotrigine.

Inspectors wroteBased on record review, staff interviews, review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers, and review of employee job descriptions, the facility failed to ensure one of 20 sampled residents (R) (R77) was free from a significant medication error related to not administering medications according to the physician orders. Specifically, R77 was ordered lamotrigine (a medication used to treat seizures) 250 milligrams (mg) extended release (ER) daily, but was only administered 25 mg per day, due to a pharmacy dispensing error. Actual harm was identified to have occurred on [DATE] when R77 suffered a grand mal seizure, as a result of a subtherapeutic dose of lamotrigine for 13 days.

Inspectors wroteBased on record review, review of the Certifying Board of Dietary Managers and interviews, the facility failed to ensure that the dietary department had a designated staff as director of food and nutrition services, was a certified dietary or food service manager, or had a similar food service management or degree to provide the daily functions/duties of a Dietary Manager. This deficient practice had the potential to affect 25 of 25 residents who received meals in the facility.

Inspectors wrote1. A review of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with diagnoses including neuropathic bladder, orthostatic hypotension, gastroesophageal reflux disease (GERD), muscle weakness, and depression. A review of the Annual Minmum Data Set (MDS) assessment dated [DATE] revealed that R5 presented with a Brief Interview for Mental Status (BIMS) of 14, indicating no cognitive impairment. A review of the Care Area Assessment (CAA) revealed R5 triggered for functional abilities (self-care and mobility), urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use. A review of the July 2024 Order Summary Report revealed that R5 was ordered to receive escitalopram 10 mg tablet one time a day related to depression, with start date of 4/3/2024. [...]

Inspectors wroteBased on record review, interview, and review of the facility policy titled Abuse/Neglect Prevention Program, the facility failed to ensure employee screening including a criminal background check was received prior to hiring one of 11 employees (Dietary Manager) reviewed for background screening requirements.

Inspectors wroteBased on record review, interviews, and review of the facility's document titled Bed Hold Letter, the facility failed to ensure written notice of the bed-hold was provided to the resident or residents' representative upon transfer to the hospital for one of two residents (R) (R20) reviewed for hospitalization. This failure had the potential to contribute to possible denial of re-admission following hospitalization for residents discharged emergently to the hospital.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that activities of daily living (ADL) care was provided for two of five dependent residents (R) (R5 and R15).

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Personnel, Foods Brought in by Family, and Food Production, the facility failed to ensure that food items were properly dated and labeled, and that staff wore proper hair restraints while in food service area. The deficient practice had the potential to affect the 26 residents on the skilled nursing unit that were receiving an oral diet.

Inspectors wroteBased on observation, record review, interviews and review of the policy titled Infection Control/Returning to Work/Epidemic Surveillance Plan, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infections. The census was 26.

Inspectors wroteBased on record review, interviews, and review of the policy titled Guidelines for Handling Multidrug-Resistant Organisms (MDRO) Management in LTCF, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to include antibiotic use protocols and a system to monitor antibiotic usage for the past 12 months. The census was 26.

Inspectors wroteBased on document review, staff interviews, and review of the policy titled Infection Prevention and Control Program, the facility failed to designate at least one qualified individual as the Infection Control Preventionist (ICP) who had completed specialized training in infection prevention and is responsible for the facility's infection prevention and control program (IPCP). This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility census is 26 residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure sufficient nurse staffing on a 24-hour bases to care for residents needs related to (1) ensuring that residents and their representatives were included and able to participate in the planning process for three of 14 sampled residents (R) (R#9, R#19, and R#16); (2) the facility did not have a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week; (3) facility failed to follow physician orders related to a treatment for a skin tear for one of 14 sampled residents (R) (R#27).

Inspectors wroteBased on interviews and record review, the facility did not have a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week.

Inspectors wroteBased on record review, interviews, and review of the policy titled Influenza Vaccine Program, the facility failed to offer and/or administer the pneumonia and influenza vaccine to four residents (R) (R#9, R#13, R#16, and R#19) of five residents reviewed for the vaccines.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents and their representatives were included and able to participate in the planning process for three of 14 sampled residents (R) (R#9, R#19, and R#16).

Inspectors wroteBased on record review, interviews, and review of the policy titled Baseline Care Plan Policy, the facility failed to develop a baseline care plan for one of 14 sampled residents (R) (R#28), that included goals and interventions to meet the immediate care needs present upon admission.

Inspectors wroteBased on record review, staff interview, and review of facility policies titled, Written Care Plan and Care Planning Procedures, facility failed to ensure the care plan for one resident (R) (R#4) was revised after a fall.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge plan was developed and documented by the interdisciplinary team based on residents needs for one of 14 sampled residents (R) (R#28).

Inspectors wroteBased on record review, staff interviews, and review of policy titled Transfer and Discharge Policy, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a post discharge plan of care, or a final summary of the resident's status for one resident (R) (R#28). The sample size was 14 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders related to a treatment for a skin tear for one of 14 sampled residents (R) (R#27).

Inspectors wroteBased on observations, record reviews, interviews, and review of the facility policy titled Fall Prevention Assessment and Management Guidelines , the facility failed to assure the safety of one resident (R#4) with a history of falls, by not applying a bed alarm while resident was asleep in bed and a chair alarm while she was up in the wheelchair and complete documentation of neuro-checks post fall. The sample size is 14.