Pruitthealth - Athens Heritage

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure unauthorized and unsecured medications were not left at the bedside for two of 41 sampled residents (R) (R17 and R86). This deficient practice had the potential to place R17 and R86 at risk of medical complications related to unauthorized medication use.

Inspectors wroteBased on observations, staff interviews, and review of the facility-provided document titled Housekeeping: Discharge and Monthly Deep Cleaning of the Resident Room, the facility failed to maintain a clean, homelike environment in two of 12 resident rooms (rooms [ROOM NUMBERS]) on the 300 Hall. This deficient practice had the potential to place the residents residing in the rooms at risk of living in an unsanitary living environment and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to ensure hazardous chemicals were not stored in one of 34 sampled residents' (R) (R9) rooms. This deficient practice had the potential to place R9 at risk of medical complications related to hazardous chemicals.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure oxygen was administered according to the physician's orders for two of 25 residents (R) (R5 and R34) receiving oxygen treatment. This deficient practice had the potential to place R5 and R34 at risk for respiratory complications.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Labeling, Dating, and Storage, the facility failed to ensure food stored in the main kitchen and in the unit kitchenette's, were labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for all residents. The facility census was 83 residents.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Advance Beneficiary Notics (ABNs), the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or Notice of Medicare Non-Coverage (NOMNC) for two out of three Residents (R) (R23 and R76) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. The sample size was 29 residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policies titled, Pneumococcal Vaccinations and Influenza (Flu) Vaccinations for Health Care Center Residents, the facility failed to provide documentation the pneumococcal and influenza vaccines had been offered, given, or previously received outside of the facility for five of five Residents (R) (R286, R23, R12, R72, and R76) reviewed for immunizations. The sample size was 29 residents.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to evaluate and determine if it was appropriate for a resident to self-administer medications for one of 29 sampled Residents (R) (R51). This failure placed the resident at risk for inappropriate and unsafe medication use.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure the call button to activate the emergency call light was accessible for one out of 29 sampled Residents (R) (R53) . This failure placed the resident at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to perform nail care for one out of 29 sampled Residents (R) (R38) requiring substantial or maximal assistance from staff for personal hygiene needs.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide podiatry services to one out of 29 sampled Residents (R) (R38). This failure had the potential to affect one resident's bilateral foot health.

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to accommodate a resident's allergies for one of 29 sampled Residents (R) (R286). Specifically, the facility served R286 foods that were documented as allergies. This deficient practice had the potential to result in harm with an allergic reaction and reduced consumption for R286.

Inspectors wroteBased on record review, interviews, and review of the policy titled Occurrence Reduction Program, the facility failed to provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). Actual harm occurred on 12/29/2022, when R1 fell out of bed and suffered a compression fracture of T2/T3 vertebrae, a laceration on her forehead which required sutures, skin tears and multiple bruises to bilateral upper extremities.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Grievances: Healthcare Centers, the facility failed to ensure prompt and thorough efforts to resolve continued resident grievances regarding call light response time, and lack of staff's response to residents unmet needs. The census was 89. Findings Include: Review of the policy titled Grievances: Healthcare Centers, revised date11/21/2022 defined a grievance as complaints with respect to care and treatment furnished to a patient, as well as that which has not been furnished. The policy is for the facility to process grievances and complaints in a prompt, reasonable, and consistent manner. All partners shall take an active part in efforts to resolve grievances and complaints without discrimination or retaliation against a person filing a grievance or complaint. [...]

Inspectors wroteBased on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement Policy (SNF), the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program that identified ongoing concerns related to resolving resident grievances and concerns related to dietary services and call light responses. The census was 89. Findings Include: Review of the Quality Assurance and Performance Improvement Policy (SNF) reviewed on 6/2/2022 revealed the purpose of the Quality Assurance and Performance Improvement (QAPI) Program is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission, and commitment to caring pledge. [...]

Inspectors wroteBased on record review, staff and resident interviews, and review of the policies titled, admission Orders and Peripherally Inserted Central Catheters (PICC), the facility failed to review, verify, document, and transcribe physician orders for one of three sampled residents (R) (R24). Specifically, R24 was admitted to facility with a PICC line, but there were no physician orders for use or care of the device.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure there was sufficient staffing to provide the assistance residents needed with activities of daily living (ADLs). This deficient practice had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure that the daily nurse staffing information was posted daily and readily accessible to residents and visitors on three of three survey dates, 9/30/22, 10/1/22 and 10/2/22. The facility census was 81.

Inspectors wroteBased on observations, staff interviews, and review of the policy titled Labeling, Dating, and Storage, the facility failed to label, and date opened food items. This deficient practice had the potential to effect 74 of 88 residents receiving an oral diet.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Advanced Directives: Georgia, the facility failed to ensure that the health records which included the physician orders, accurately reflected the code status wishes for two residents (R) (R#7 and R#17). The sample size was 33 residents.

Inspectors wroteBased on record review, staff interview, and review of the facility procedure titled Lippincott procedures-SBAR (situation, background, assessment, recommendation) Communication, the facility failed to notify the Physician and responsible party (RP) of a change in condition for one resident (R#86). The sample size was 33 residents.

Inspectors wroteBased on observation, record review, interviews, and review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to report an injury of unknown origin for one resident (R) (R#77) of 33 sampled residents. Findings Include: Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 7/29/19, revealed any injury of unknown source should be immediately reported to the Administrator of the provider entity. Further review revealed the State should be notified within two hours after the unknown injury is reported or identified. The Administrator or designee would then direct an investigation into the incident. Additionally, the Ombudsman should also be notified as required by State law. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled Bed Holds and Room Reserves, the facility failed to provide written bed hold information to the resident or the resident's representative when residents were transferred to the hospital for one resident ( R) (R#85) of 33 sampled residents reviewed for transfers.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure the Minimum Data Set (MDS) information was accurately documented for four of 33 sampled residents.

Inspectors wroteBased on record review, staff interviews, and review of the policy titled, Care Plans, the facility failed to develop a person-centered care plan for one resident (R) (R#135) for incontinence; and failed to follow the care plan for two residents (R#20 and R#45) for activities of daily living (ADL) care. The sample size was 33 residents.

Inspectors wroteBased on record review, and staff interview, the facility failed to develop a discharge plan with an Interdisciplinary Team (IDT) meeting for one resident (R) (R#85) of 33 sampled residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that activities of daily living (ADL) were provided for two dependent residents (R) (R#20 and R#45) related to personal hygiene including dressing and facial hair care. The sample size was 33.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Medication Administration: Enteral Tubes, the facility failed to ensure appropriate care of a gastrostomy (g)-tube during medication administration for one resident (R) (R#47), who was observed during the observation of medication administration, by failing to verify placement or check residual prior to administering medications.

Inspectors wroteBased on observation, record review, interviews, and review of the Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement, the facility failed to provide evidence for ongoing communication between the facility and the dialysis center for one resident (R) (R#61) of two residents reviewed for dialysis.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure that psychotropic medications were not ordered as needed (PRN) beyond 14 days and failed to document the reason for the extension or the period during which the extended order should be in effect for two residents (R ) (R#243 and R#45), of five residents reviewed for unnecessary medications.