Tattnall Healthcare Center

Inspectors wroteBased on interview, record review, record review, and review of the facility's policy titled, Infection Prevention 8.3, the facility failed to implement policies and procedures to ensure an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotics were ordered in order to reduce the development of antibiotic-resistance organisms for residents prescribed antibiotics in the facility. In addition, the Antibiotic Stewardship Program lacked documentation of the tracking or trending of antibiotic usage or where infections occurred in the facility. This failure had the potential to affect all residents' safety related to antibiotic usage and increased the risk of antibiotic-resistance. The facility census was 72 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve food that was palatable and hot for three of five residents (R) (R25, R26, and R47) reviewed for food palatability out of a total sample of 33 residents. This failure had the potential for the residents to skip meals and potential for weight loss.

Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines at https://www2a.cdc.gov/vaccines/m/pneumo/pneumo.html, and review of the facility's policy titled, Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4, the facility failed to offer and provide pneumococcal vaccines for five of five Residents (R) (R25, R1, R29, R16, and R47) reviewed for pneumonia vaccinations and failed to ensure R25 received an influenza vaccine. This practice had the potential to increase the risk for these residents to contract pneumonia or influenza.

Inspectors wroteBased on interview, record review, and review of the facility's policy titled Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4.1, the facility failed to offer and provide COVID-19 vaccines for five of five Residents (R) (R25, R1, R29, R16, and R47) reviewed for COVID-19 vaccination out of a total sample of 33. This practice had the potential to increase the risk for these residents to contract COVID-19.

Inspectors wroteBased on interview, record review, and review of the facility's policy titled Freedom of Abuse- Abuse Prevention: Fast Alerts, the facility failed to ensure two of four Residents (R) (R14 and R80) reviewed for abuse were free from resident-to-resident physical abuse. This failure had the potential to negatively impact all residents due to the facility's failure to prevent resident abuse.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two of five Residents (R) (R47 and R5) reviewed for accuracy of MDS assessment out of a total sample of 33 residents. This failure placed the residents at risk of having unmet care needs and services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the Pre admission Screen and Resident Review (PASARR) level screening was accurately completed prior to admission for one of one Resident (R) (R29) reviewed for PASARR out of 33 sampled residents. This failure had the potential not to identify the specialized services R29 may have needed and if R29 was appropriate for admission to the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled Elopement Management, the facility failed to provide adequate supervision for one of four Residents (R) (R81) reviewed for accidents. Specifically, R81 eloped from the facility and the facility grounds without staff knowing the resident was missing, which placed him at risk for the resident to be in harm's way or a possible injury.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policies titled, Food Storage, and Sanitation & Food Production, the facility failed to ensure the kitchen was maintained in a sanitary manner for 64 out of 65 residents receiving an oral diet. Specifically, the facility failed to ensure dietary staff allow the clean dishware to air dry; change gloves after touching soiled dishes, removing clean dishware from dish washer without performing hand hygiene; label and date food stored in reach in cooler and freezer, bulk food item containers had a scoop properly stored; directly touching food items with contaminate gloves during meal service, chemicals were not labeled with the name of the product inside. This created the potential for the spread of foodborne illness.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure four out of 64 residents (Resident (R)34, R26, R13, R32) who received meals prepared by the dietary department were served palatable food, and approximately 35 residents in the dining room did not receive condiments of salt and pepper. Specifically, the food was not at the proper temperature when residents were served; the food lacked flavor; condiments were not provided; food presentation and texture were unappealing.

Inspectors wroteBased on staff interviews, record review, review of the facility policy titled, Change in Condition/Incident Reporting, and review of the American Heart Association website, the facility failed to notify the physician of a change in condition for one of six Residents (R)63). Specifically, the facility failed to ensure the physician for R63 was notified of residents' significantly elevated blood pressure readings.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Bed-Hold, the facility failed to ensure two of two (Residents (R) 25 and R168) and their resident representatives had a written Bed-Hold Notice when the residents were transferred to the hospital.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Advance Directives, the facility failed to ensure one of 34 residents (Resident (R)25) had clear and consistent information available regarding whether to perform cardiopulmonary resuscitation (CPR). Specifically, R25's status changed to Do Not Resuscitate (DNR) following admission to hospice; this information was not consistently documented in the resident's record, creating the risk staff would not know whether to attempt to resuscitate him in the event he had no pulse or he stopped breathing.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled, Respiratory System Management, Oxygen E-Tanks, the facility failed to ensure one of six residents (Resident (R)44) portable oxygen tank was securely stored while in residents room.

Inspectors wroteBased on observations, resident and staff interviews, review of facility documents, and review of facility policy titled COVID-19 Protocol Phase IV, the facility failed to ensure infection control practices were followed to prevent the transmission and spread of COVID-19 related to cohorting a COVID positive residents (R1) and COVID negative resident (R2) in the same room on one of three halls.

Inspectors wroteBased on observations, document review, staff interviews, and review of the facility's dishwasher procedure, the facility failed to ensure the dishwasher was operating per manufacturer's requirements to ensure dishes were sanitized and failed to ensure a fan was free of dust and debris while operating in one of one kitchen. The deficient practice affected 70 of 72 residents receiving an oral diet.

Inspectors wroteBased on observations, interviews, and review of a facility policy titled, Resident Rights and Dignity Management, the facility failed to ensure that residents were afforded the opportunity to use a telephone in a private setting on two (Hall A and Hall B).of three halls.

Inspectors wroteBased on observations, interviews, and policy review, it was determined the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program was in place. Specifically, the facility's QAPI Program failed to identify, implement, or monitor corrective interventions to ensure residents had a functioning call system. The facility census was 72 residents. (Cross refer to F919.)

Inspectors wroteBased on observations and interviews, the facility failed to maintain a functioning call bell system for 12 of 21 sampled resident . During the initial tour of facility on 07/05/2022, a concern was identified with the resident call bell system. There were 12 resident rooms identified with a non-functioning call bell (Rooms 4, 6, 7, 9, 11, 14, 16, 20, 21, 33, 35, and 39). Resident rooms 4, 9, 16, 20, 35 and 39 were noted with a round call disk that had temporarily been put in place to use for the call bell and were also found to be non-functional.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the discharge planning process was documented in the medical record for one (Resident [R] #223) of two sampled residents reviewed for discharge planning.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that one [Resident (R) #15] of 21 residents whose care plans were reviewed had a person- centered care plan to address contractures.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to revise the care plans for one [Residents (R) #223] of 21 sampled residents reviewed for care planning. Specifically, R#223's care plans were not revised to include a change in code status and discharge care planning.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to investigate to determine the causal factors of a fall for one (Resident [R]#49) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for two [Residents (R) #52 and #223] of 21 residents whose medical records were reviewed regarding code status to denote if a resident desired life-saving measures, to include cardiopulmonary resuscitation (CPR).