Newnan Health And Rehabilitation

Penalty

Inspection fine: $25,847

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent accidents for a resident, resulting in a fall with a major injury. The resident, who had a history of falls, was being transported in a wheelchair by the Activities Director when the wheelchair suddenly stopped, causing the resident to fall forward and hit her head. This incident led to a major injury, including a right forehead laceration, soft tissue hematoma, and a fracture involving the cervical spine. The resident had previously reported issues with sitting on the wheelchair cushion, noting that she was sliding forward. Despite this, no defects were observed in the cushion, and a physical therapy referral was ordered to assess and treat the issue. On the day of the fall, the Activities Director left the resident unattended in the hallway to respond to another resident, during which time the resident fell from the wheelchair. Interviews with staff revealed inconsistencies in the account of the incident, with some staff members unaware of the fall until days later. The Director of Nursing at the time did not conduct a thorough investigation, and the Administrator did not interview other staff members present during the incident. The lack of immediate and comprehensive investigation into the fall and the failure to address the resident's reported issues with the wheelchair contributed to the deficiency.

Removal Plan

• A therapy screen was done for R13 by the Physical Therapist. A Physical Therapy assessment was completed for R13. The Social Worker completed a behavioral assessment. No changes were identified for R13. A care plan conference was held with R13 and her family with the Social Worker, the RAI Registered Nurse (RN), the Licensed Practical Nurse (LPN), the Restorative Nurse, the Dietary Manager, the Charge Nurse LPN, the CNA. R13 stated she had no problems or concerns. Speech Therapy completed an assessment for R13. The Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. The Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth q day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. A Medical Doctor assessed R13, with no concerns noted at that time. The Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated by a licensed practical nurse, and by an RN for R13.
• The DON who conducted the original investigation is no longer employed; she resigned. Newly hired DON began a new root cause analysis. The root cause was completed for R13.
• An ad hoc Quality Assurance Process Improvement (QAPI) and performance improvement plan (PIP) was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division [NAME] President, Administrator, Division Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, Admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed.
• The Division [NAME] President and Divisional Nurse provided education to the Administrator, DON, and Social Worker on the job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EMR to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EMR upon admission/readmission and post-fall as indicated. Nurses are to follow up with therapy to ensure a timely review of referrals. Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed. (Patient exhibiting any signs/symptoms of anxiety such as restlessness, nausea, elevated heart rate, difficulty sleeping). If the patient is noted to exhibit signs of anxiety, nursing to assess the patient and report to the provider as indicated. The Administrator, the DON, and the Social Worker received education.
• Corrective action for other residents having the potential to be affected by the same deficient practice: All residents who reside in the facility who are transported and have had a fall have the potential to be affected by the alleged deficiency.
• Systemic changes are made to ensure that the deficient practice will not recur. Oversight was provided by the Divisional Nurses (DN) to ensure the DON completed a root cause analysis of residents with falls. Oversight by DN to ensure that 8 of 8 therapy referrals were completed by the RAI coordinator was completed. Oversight by DN of Social Worker to confirm that eight or eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, including weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by a Regional Dietitian. DVP and DN made observational rounds to supervise the Administrator, DON, and Social Director of the day-to-day operations to include adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. DN attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. DVP and DN confirmed that education had been completed with staff for falls and safety transportation.
• Quality Assurance plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection Grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the POC. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this POC will be validated by the DVP and /or DN and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary.
• All corrective actions were completed. The facility alleges that the IJ was removed.

Penalty

Inspection fine: $25,847

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's administration failed to address significant concerns regarding fall management and the transportation of residents within the facility. This deficiency was highlighted by the case of a resident who experienced multiple falls, with the most severe occurring on November 1, 2024, resulting in a major injury. The resident was admitted to an acute care hospital with serious injuries, including fractures and a laceration, following the fall. Despite these incidents, the facility did not conduct a thorough investigation or root cause analysis to understand and mitigate the risks associated with these falls. The Administrator, who had been in the position for two years, did not complete a full investigation into the fall incident on November 1, 2024, as the former Director of Nursing (DON) advised that it was not a reportable incident. The Administrator's inquiry was limited to asking the Activities Director about the incident, without interviewing other staff members who were present at the time. This lack of comprehensive investigation and analysis contributed to the facility's failure to implement necessary changes to prevent future occurrences. The facility's administration also did not ensure that a therapy assessment and psychosocial harm assessment were completed for the resident post-fall. Additionally, there was a lack of staff education on safely transporting residents within the facility, which further contributed to the risk of accidents. These oversights and failures in addressing the fall management and transportation procedures led to the determination of noncompliance with federal, state, and local regulations governing long-term care centers.

Removal Plan

• A therapy screen was done for R13 by the Physical Therapist. A Physical Therapy assessment was completed for R13. The Social Worker completed a behavioral assessment. No changes were identified for R13. A care plan conference was held with R13 and her family with the Social Worker, Registered Nurse, Licensed Practical Nurse, Restorative Nurse, Dietary Manager, Charge Nurse LPN, and CNA. R13 stated she had no problems or concerns. Speech Therapy completed an assessment for R13. The Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. The Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth every day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. A Medical Doctor assessed R13, with no concerns noted. The Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated by an LPN, and by an RN for R13.
• Newly hired DON began a new root cause analysis. The root cause was completed for R13.
• An ad hoc Quality Assurance Process Improvement and performance improvement plan was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division President, Administrator, Divisional Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, Admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed.
• Division President and Divisional Nurse provided education to the Administrator, DON, and the Social worker on job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EHR to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EHR upon admission/readmission and post-fall as indicated. Nursing to follow up with therapy to ensure timely review of referral. Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed.
• Oversight was provided by the Divisional Nurse to ensure the DON completed a root cause analysis of residents with falls. Oversight by the Divisional Nurse to ensure that eight of eight therapy referrals were completed by RAI coordinator was completed. Oversight by Divisional Nurse of Social Worker to confirm that eight of eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, to include weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by the Regional Dietitian.
• The Division President and the Divisional Nurse made observational rounds to supervise the administrator, DON, and Social Worker of the day-to-day operations including adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. The Divisional Nurse attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. The Division President and the Divisional Nurse confirmed that education had been completed with staff for falls and safety transportation.
• Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the Plan of Correction. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this plan of correction will be validated by the Division President and /or Divisional Nurse and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary.
• The facility alleges that the IJ was removed.

Penalty

Inspection fine: $25,847

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate activities of daily living (ADL) care for three residents, leading to unmet needs and a diminished quality of life. Resident 34, who is legally blind and has a history of falling, was observed with long, unclean fingernails with a dark brown substance underneath. Despite being cognitively intact and requiring substantial assistance with ADL care, the resident's need for nail care was not addressed, as confirmed by a Certified Nursing Assistant (CNA) who had not been assigned to the resident recently. Similarly, Resident 36, who has type 2 diabetes mellitus, hemiplegia, and cerebral infarction, was also found with long, unclean fingernails. Despite being dependent on staff for ADL care, the resident reported infrequent nail care. Resident 43, diagnosed with depression and requiring substantial assistance with ADL care, was observed with long, dirty fingernails. The resident was unsure of the frequency of nail care provided, and a CNA was unable to explain why the resident's nails were not cleaned. The Director of Nursing, new to the facility, acknowledged the expectation for staff to provide nail care but was still familiarizing herself with the facility's operations.

Penalty

Inspection fine: $25,847

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain an active physician order for oxygen therapy and implement appropriate infection control measures for a resident, identified as R489. The resident was admitted with diagnoses including dyspnea and was noted to have shortness of breath at rest, requiring oxygen therapy. However, the physician's order for oxygen therapy was discontinued, and no new order was obtained, despite the resident continuing to receive oxygen. This oversight was confirmed during interviews with the LPN and Admissions Coordinator, who acknowledged the need for an active order for oxygen therapy. Additionally, infection control practices were not followed as the nasal cannula used by the resident was observed not to be stored properly when not in use. The nasal cannula was found hanging off the oxygen concentrator and touching the floor, rather than being placed in a plastic bag as required. This was confirmed by the LPN and the Director of Nursing, who stated that the nasal cannula should be bagged when not in use to prevent contamination.