Rehabilitation Center of South Georgia

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Self-Administration of Medications and Storage of Medications, the facility failed to ensure three of 36 sampled residents (R), (R88, R95, R41) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to R88, R95, and R41, other residents, unauthorized staff, and visitors.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Care Plans-Comprehensive, the facility failed to follow care plans for one of 36 sampled residents (R) (R77). This deficient practice had the potential to place R77 at risk of not receiving treatment and/or care in accordance with their needs.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure that one of six residents (R) (R84) receiving nourishment via a tube feeding received water flushes as ordered by the physician. This deficient practice had the potential to place R84 at increased risk of medical complications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that one of 19 residents (R) (R77) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R77 at risk for respiratory complications and a diminished quality of life.

Inspectors wroteBased on observations, staff and family interviews, and review of the facility's policy titled, Food Serving Temperatures, the facility failed to provide food at a safe and appetizing temperature for one observed meal. This failure had the potential to affect the satisfaction of food and palatability for 115 of 119 residents consuming food from one of one kitchen at the facility.

Inspectors wroteBased on observation, staff interview, and review of the facility's policy titled, Garbage and Rubbish Disposal, the facility failed to ensure garbage was properly disposed of and contained for two of three dumpsters with the side doors pushed back and left open. This had the potential to attract pests and affect the residents and staff at the facility. The facility census was 119 residents.

Inspectors wroteBased on observation, record review, interview, and review of the facility's policy titled, Care Plans-Comprehensive, the facility failed to implement a person-centered comprehensive plan of care with measurable goals and plans related to fall and activity interventions for five of six residents (R) R43, R84, R60, R55, and R101) reviewed for care plans. This failure had the potential for residents with a diagnosis of dementia to be disruptive to other residents and staff due to the lack of engagement in daily activities and had the potential for injury without proper fall interventions in place as directed by the plan of care.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Activities and Social Services, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for four of six residents (Residents (R) 101, R60, R93, and R55), who resided on the memory care unit and reviewed for activities. This failure had the potential for residents with diagnoses of dementia, to be disruptive to other residents and staff due to the lack of engagement in daily activities.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Exercise of Rights, the facility failed to honor residents' rights to be able to get out of bed as the resident chooses for one of 25 sample residents (Resident (R) 36). This failure resulted in the potential for R36 not being able to get out of bed due to the facility not having the available equipment.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Policy and Procedures, the facility failed to protect the residents' right to be free from physical abuse by another resident for four out of 25 residents (Residents (R) R60, R55, R101, and R93) that were reviewed for abuse.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Policy and Procedures, the facility failed to implement their abuse policy related to employee screening. The facility failed to ensure references were checked prior to employment for three of ten employees whose employee files were reviewed.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse Investigation the facility failed to ensure thorough investigations were conducted of resident-to-resident incidents for four of 25 residents (Residents (R) 60, R55 R90, and R68) reviewed for abuse. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Discharging the Resident, the facility failed to provide the receiving facility with documentation regarding the transfer for one of five resident (R) (R86) reviewed for hospitalization. This failure had the potential to affect the care provided by the receiving facility by not informing them of the resident's medical needs or the residents wishes for ongoing care.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Notice of Transfer/Discharge, the facility failed to notify the resident and/or resident's responsible party and the Ombudsman of a transfer or discharge in writing for one of five resident (R) (R86) reviewed for hospitalization. This created a potential for the resident or their representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process.

Inspectors wroteBased on interview, record review, and review of the facility policy titled, Bed Hold Policy, the facility failed to ensure one of five residents (R) R86 reviewed for hospital transfers was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for the resident and/or responsible parties to not have the information needed to safeguard their return to the facility.

Inspectors wroteBased on observations, interview, record review, and review of the facility's policy titled, Fall Management, the facility failed to ensure an accident prevention measure (bed in lowest position and/or fall mat in place) was implemented for two of five residents (R) R43 and R84. This failure had the potential to cause harm if the residents fell from their bed and the proper fall interventions were not in place.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled, Medication Ordering and Receiving from Pharmacy, the facility failed to have a physician ordered medication available for administration for one of seven residents (Resident (R) 9) during the medication administration observation. This failure had the potential to decrease the effectiveness of the medication rivastigmine (Exelon) patch which was used for dementia.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Consultant Pharmacist Reports, the facility failed to ensure pharmacy medication regimen reviews (MRR's) included appropriately monitored medication regimens to include antibiotic usage and ensure that medications received were clinically indicated for one of six residents (Resident (R) 63) reviewed for medication regimens. The failure had the potential to affect resident safety related to antibiotic use.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policies titled, Crushing Medications, and Administrating Oral Medications, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for one resident (Residents (R) 77) were made of 27 opportunities during medication administration resulting in a medication error rate of 7.41 percent. These failures had the potential to increase or decrease the effectiveness of these medications.

Inspectors wroteBased on observation, interviews, record review, and review of the facility's policy titled, Medication Administration-General Guidelines, the facility failed to ensure one of six medication carts were locked and a cup of medications was not readily accessible while left unattended with the potential to affect one of two residents (R) R79. This failure had the potential for R79 to have access to medications that were not prescribed for him that could lead to adverse side effects.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies titled, Handwashing/Hand Hygiene, Dressing Change, Contact Precautions, and Administering Oral Medications, the facility failed to use proper infection control guidelines for a dressing change, during medication pass, and for contact isolation for three of three residents (R) R8, R75, and R77 reviewed for infection control. This failure had the potential for the spread of infections.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Antibiotic Stewardship Program Overview, the facility failed to monitor, evaluate antibiotic use, and track measures of antibiotic usage for one of three residents (Resident (R) 63) reviewed for antibiotic usage. This failure had the potential to affect resident safety related to antibiotic usage.

Inspectors wroteBased on staff interview, and record review the facility failed to ensure that the facility's Social Service Director had the proper qualifications for a facility with over one-hundred and twenty (120) beds.

Inspectors wroteBased on review of video surveillance, record review, staff interviews, and review of the facility policy titled, Abuse Prohibition Policy and Procedure, the facility failed to ensure residents on the Memory Care Unit, which contained 15 resident rooms, were free from involuntary seclusion when Certified Nursing Assistant (CNA) CC placed bath linens on top of resident room doors to keep residents from opening their doors. The total sample was 14 residents.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Disposal of Medications and Medication-Related Supplies, the facility failed to ensure fentanyl patches were destroyed in the presence of two licensed nurses and documented on the Certificate of Inventory and Destruction for Reverse Distribution form for one resident (R) (R#9). The total sample was 14.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Care of Facility Property, the facility failed to ensure that the feeding pumps for three (3) of four (4) residents (R) (R#2, R#5, and R#26) who received nutrition through a gastrostomy tube (tube inserted into the stomach) were clean and sanitary. The facility also failed to ensure that the facility was maintained in a clean and sanitary condition related to scuffed walls in rooms [ROOM NUMBER] and dirty air vents outside of rooms [ROOM NUMBERS]. Specifically, the facility failed to ensure that the feeding pumps for R#2, R#5, and R#26 were clean and sanitized to prevent build-up of dirt and debris and to ensure that the air vents were free of dust and debris in the residents' living area.

Inspectors wroteBased on record review and interviews, the facility failed to apply for a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of two residents (R) #87 that had a positive level I PASRR for mental illness. Specifically, R#87 had diagnosis of Bipolar and Major Depressive order prior to and on admission to the facility that was not addressed.

Inspectors wroteBased on Record Review, staff interviews, and review of policy titled, Goals and Objectives, Care Plans the facility failed to implement plan of care for one of 35 residents (R) R#267 related to Activities of Daily Living (ADL) not receiving a Shower/Bath. Findings Include: A review of the policy titled, GOALS and Objectives, Care Plans dated 4/18/2017 under Policy Statement: Care Plans shall incorporate goals and objectives that lead to the residents highest obtainable level of independence. Policy Interpretation and Implementation 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 5. Goals and objectives are reviewed and/or revised b. when the desired outcome has not been achieved. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Shower/Tub Bath the facility failed to ensure that activities of daily living (ADL) were provided for one of 23 residents (R) R#267. Specifically, the facility failed to ensure that R#267 received scheduled showers and baths.

Inspectors wroteBased on Observations, Interviews, and record review, the facility failed to ensure that respiratory equipment was properly stored when not in use to minimize the potential for respiratory infections for one of 26 Residents (R)#62 related to Continuous positive airway pressure (CPAP) masks and oxygen nasal canula (NC) were not properly stored. Findings Include: Review of the medical record for R #62 revealed resident was admitted to the facility with diagnoses that include but is not limited to Acute and chronic respiratory failure, Chronic Atrial Fibrillation, Heart Failure, and Hypertension. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. [...]