Pruitthealth - Fairburn

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure food items were properly dated, labeled, and stored; failed to ensure an ice machine was free from a black spotted substance; and failed to perform proper hand hygiene while handling food to prevent contamination. The deficient practice had the potential to affect 68 of 68 residents that received an oral diet.

Inspectors wroteBased on observations, staff interviews, record review and review of the facility policy titled, Intravenous (IV) Antibiotic Therapy, the facility failed to provide care that met professional standards for one of two residents (R) (R124) receiving intravenous (IV) antibiotics therapy. The deficient practice has the potential to place R124 at risk for lack of healing of infection, clotting of IV line, and sepsis.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies, How to Puree Food and Puree Vegetable Blend - 4 ounces (oz), the facility failed to follow a recipe and use measurement devices when preparing puree food for three of seven residents receiving a puree diet. The deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increased risk of aspiration.

Inspectors wroteBased on resident, family and staff interviews, and record review, the facility failed to provide written notification to the resident and the resident representative (RP) with an explanation of why the move to a new room was required for one of 36 samples resident (R) (R275).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure the safe and sanitary storage of dentures for one of 36 sampled residents (R) (R224). Specifically, dentures were not stored in a labeled denture cup and the upper denture was found on an unclean surface rather than in a designated labeled container. The deficient practice had the potential to cause contamination, misplacement or damage of R224's denture.

Inspectors wroteBased on observation, record review, staff interviews, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to ensure that all medications were taken and not left unattended on the bedside table for one of 36 sampled residents (R) (R224). The deficient practice had the potential to increase the residents risk of adverse health outcomes related to incorrect medication dosage.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to have a physician's order for oxygen (O2) administration and failed to provide the correct O2 liter flow per physician's order for two of 15 residents (R) (R64 and R5) receiving oxygen therapy. The defieicent practice had the potential for R64 and R5 to have respiratory issues with O2 set at the incorrect level.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled, Controlled Substances for Healthcare Center, the facility failed to ensure that controlled substances were documented immediately after administration for three of 36 sampled residents (R) (R32), (R17) and (R275), in accordance with accepted standards of nursing practice. This deficient practice had the potential to cause medication errors, including overdoses.

Inspectors wroteBased on observations, interviews, and record reviews, and review of the facility policies titled, Infection Prevention and Control Plan and Infection Prevention Control and Surveillance, the facility failed to ensure appropriate infection control practices were implemented by staff to prevent the spread of infection for one of 36 sampled residents (R) (R40). Specifically, staff failed to perform hand hygiene when entering and exiting rooms on contact precautions, and properly clean and disinfect reusable medical equipment. The deficient practices had the potential to contribute to the transmission of communicable diseases and place residents at risk for infection.

Inspectors wroteBased on resident, resident representative, and staff interviews, record review, and review of the facility's arbitration agreement, the facility failed to inform three of three sampled residents (Resident (R) 64, R30 and R9) and/or their resident representatives reviewed for arbitration agreements that signed arbitration agreements, that the provisions of this agreement shall remain in effect after any other agreements between the parties have been terminated, and this agreement shall survive the death of a patient. Findings Include: Review of a blank copy of the facility's Arbitration Agreement, provided by the facility, indicated, . Scope of Agreement. Any and all disputes between the Patient and the Center shall be submitted to binding arbitration, except claims that may be brought in the applicable State small claims court. [...]

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Grievance: Healthcare Center, the facility failed to act to resolve resident council grievances regarding the facility failing to serve food that was palatable and hot at meals for 13 of 18 sampled residents (Resident (R)12, R21, R64, R41, R32, R33, R7, R30, R9, R55, R3, R11 and R20) who attended the monthly Resident Council meetings. Findings Include: Review of the facility policy titled, Grievance: Healthcare Center, revision date 11/21/2022, specified, The Administrator of each healthcare center serves as its grievance official and is responsible for the following: overseeing the grievance process; receiving and tracking grievances through to the conclusion; leading necessary investigations; [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to ensure that two of five residents (Residents(R)27 and R55) observed during medication administration, received their medications within either the hour before or the hour after the physician ordered administration time. The deficient practice could result in a resident not maintaining a therapeutic level of the prescribed medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Meal Delivery, the facility failed to serve food that was palatable and hot to 4 of 18 sampled residents (Resident (R)12, R7, R17, and R37) interviewed for food palatability.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Infection Prevention-Hand Hygiene, the facility failed to ensure that hand hygiene was performed during medication administration for two of five residents (Residents(R)55 and R56) observed during the medication administration task. The deficient practice had the potential to spread infection.

Inspectors wroteBased on observations, interview, and review of the facility policy, the facility failed to serve food in the kitchen under sanitary conditions. This problem can affect 53 of 60 residents that take food by mouth.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure comprehensive care plans were developed to reflect residents care needs for two residents (R) (R#217 and R#5) of 22 sampled residents related to oxygen therapy for R#217 and treatment to prevent further decline of contractures for R#5.

Inspectors wroteBased on closed record review, and interview, the facility failed to complete a recapitulation of stay for one resident (R) (R#47) of three residents reviewed for discharge.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents centered care and services, were in accordance with the goals for care and professional standards of practice were provided for two residents (R) (R#8 and R#21) of seven residents reviewed for medication administration. Specifically, Licensed Practical Nurse (LPN)1 did not prepare and deliver R#8 and R#21 medications for administration simultaneously.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide treatment/services, equipment, supplies and/or assistance to maintain or improve ROM (range of motion)]/mobility for one resident (R) (R#5) out of two residents sampled for ROM. Finding Include: Review of facility-provided policy titled, Therapy Patient/Resident Referral, dated 5/20/21 revealed, It is our policy for a therapy referral form to be completed within Matrix .Nursing should complete an interdisciplinary referral form in the Matrix if a patient has shown changes in condition or has new impairments that should be assessed by therapy .The therapist(s) will review the Interdisciplinary form in the Matrix and verify therapy orders are written for an evaluation . [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure residents' respiratory equipment was properly stored when not in use; and failed to follow physician's orders (oxygen flow rate) for two residents (R) (R#216 and R#217) of two residents reviewed for oxygen therapy. R#216's nebulizer masked was not stored properly allowing the mask to be exposed to environmental germs. Additionally, R#216 and R#217's physician order for oxygen flow rate was not followed which could lead to possible respiratory distress and their oxygen tubing was not dated to indicate when it was last changed.

Inspectors wroteBased on observations, record reviews, staff interviews, and policy review, the facility failed to ensure controlled medications records were maintained and accounted for one (300 Hall Medication Cart) of three medication carts. A narcotic count of R#26's Tramadol (an opiate, controlled substance that was subject to abuse) on 3/10/22 did not reconcile with the resident's controlled medication record.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were secure for one of three medication carts. The medication cart contained loose and unidentified medications. Additionally, the facility failed to ensure four residents (R) (R#10, R#50, R#42, and R#215) of 22 resident's medications were stored securely in the medication cart.