Chatuge Regional Nursing Home
CHATUGE REGIONAL NURSING HOME in HIAWASSEE, GA — inspection on June 8, 2024.
Found 23 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R56's Record of Admission, located under the Clinical tab of the electronic medical record (EMR), revealed R56 was admitted to the facility on [DATE].
Review of R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2024 and located under the Clinical tab of the EMR, revealed R56 scored 15 out of 15 on the Brief interview for Mental Status (BIMS), which indicated R56 was cognitively intact.
During an interview on 6/4/2024 at 11:42 am, R56 stated he needed assistance getting his license so he could vote. R56 stated when he went to vote last time, he only had a copy of his identification card, and they would not accept the copy, so his vote did not count. He indicated that it was important to him that he vote as he has never missed a vote in his life. R56 said the facility is aware of what he needs but no one has helped him.
During an interview on 6/5/2024 at 4:30 pm, the Activities Director (AD) stated he was aware that R56 needed to renew his identification card but confirmed he had not done anything about it.
During an interview on 6/6/2024 at 5:15 pm, the AD revealed he had taken R56 to get his identification card.
During an interview on 6/7/2024 at 2:00 pm, the Social Services Director (SSD) and the Director of Nursing (DON) verified that the AD would have been responsible for ensuring R56 had his identification card updated.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
grievance form was important.
She indicated if the grievance involved nursing then she would be
Cross Reference F-F600.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
jeopardy to resident health or safety
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of additional information in the
jeopardy to resident health or three debit cards that were all declined. He stated I don't know who is spending all my money. safety Review of an untitled document, dated 6/3/2024, written by the Administrator revealed R71 returned
emergency contact.
The Administrator spoke with the staff member about her being listed as the emergency contact on the hospital medical records for R71. He reiterated to her their prior conversation from 7/12/2023. CNA 1 would not respond to the Administrator during this conversation.
CNA 1 then requested a piece of paper from the Administrator and proceeded to write her resignation letter and presented it to the administrator.
During an interview on 6/6/2024 at 10:48 pm, the Administrator confirmed he did not thoroughly investigate the allegations of exploitation of R71 by CNA 1 as he felt they were rumors and had no further information to provide.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of additional information in
jeopardy to resident health or declined.
Resident stated, I don't know who is spending all my money.
There was no evidence this safety incident was reported to the SSA.
Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024.
Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip.
This note further revealed R71 was not able to move his leg on that side and knee and foot appeared very swollen. R71 was immediately sent to the emergency room. On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery.
There was no evidence that the injury of unknown origin was reported to the SSA.
- Review of R107's Record of Admission, located under the Clinical tab of the EMR revealed R107
was admitted to the facility on [DATE] with a diagnosis of Hemiparesis.
Review of the Discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact.
The resident required supervision for lower body and toileting.
Review of the Grievance Form dated 4/22/2024 revealed that R107 submitted a grievance form when the facility received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend.
When Social Services spoke with R107 he advised that that CNA 2 would not assist him to the bathroom and told him to go in his pull up. He further stated CNA 2 did not get him up all weekend.
There was no evidence the incident was reported to the SSA.
During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed the exploitation, injury of unknow origin, and verbal abuse were not reported to the SSA.
Cross Reference F-F600.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of additional information in the report revealed R71 attempted to pay his bill and he presented three debit cards that were all
incident was reported to the SA.
Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024.
Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip.
This note further revealed R71 was not able to move his leg on that side and knee and foot appeared very swollen. R71 was immediately sent to the emergency room. On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery.
There was no evidence that the injury of unknown origin was investigated by the facility.
During an interview with the Administrator on 6/6/2024 at 10:48 pm, he confirmed the above incidents involving R71 were not thoroughly investigated.
- Review of R78's Record of Admission located under the Clinical tab of the EMR revealed an
admission date of 2/2/2023 with a diagnosis of dementia.
Review of R78's significant change MDS dated of 3/21/2024 revealed a BIMS score of a zero out of 15 which indicated R78 was severely cognitively impaired.
Review of the Facility Reported Incident (FRl) dated 3/22/2024, completed by the administrator/abuse coordinator, revealed a report of verbal abuse to R78 by CNA 2.
Further review of this FRI revealed no documentation of an investigation.
During an interview on 6/6/2024 at 9:20 am, the Administrator revealed he had investigated the issue but misplaced all documentation related to this incident. He was unable to provide or report the outcome of the investigation and confirmed CNA 2 continued to provide care to R78 and other residents.
- Review of R107's Record of Admission, located under the Clinical tab of the EMR revealed R107
was admitted to the facility on [DATE] with a diagnosis of Hemiparesis.
Review of R107's discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact.
The resident required supervision for lower body and toileting.
Review of the Grievance Form dated 4/22/2024 revealed that R107 submitted a grievance when the facility received a message from resident's granddaughter stating that the resident was not allowed to use the bathroom over the weekend.
When Social Services spoke with R107 he advised that that CNA 2 would not assist him to the bathroom and told him to go in his pull up. He further stated she did not get him up all weekend.
There was no evidence the incident was investigated by the facility.
During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed there was an allegation of abuse reported by R107 against CNA 2 and the facility did not complete a thorough investigation of the abuse.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
During an interview on 6/7/2024 at 1:50 pm, with the representative of R1 revealed she was with him at a doctor's appointment, and she called and told the nurse his symptoms.
When we got back to the facility the doctor was there and gave orders to send him to the hospital.
The representative stated she did not receive anything in writing about the transfer.
- Review of R72's Face Sheet from the EMR Face Sheet from the Report tab showed a facility
admission date of 9/28/2022.
Review of R72's EMR Progress Note revealed on 5/30/2024 at 6:59 pm the nurse documented a change in mental status, decreased intake, increased sleeping, and a lack of response to stimuli; the physician was notified and an order to send to the ER was received; and R72's representative was notified by phone.
Further review of the EMR did not show any documentation of a written notice of transfer provided to R72 or her representative.
During a telephone interview on 6/7/2024 at 8:06 pm, the representative for R72 stated he had not been given a written transfer notice, was notified (by phone) and was at the hospital when R72 arrived.
- Review of R101's Face Sheet from the EMR Reports tab showed a facility admission date of
3/19/2024.
Review of R101's Progress Note revealed on 3/15/2024 at 6:47 pm the nurse noted labored breathing and a decrease in his oxygen saturation.
The nurse contacted the physician and received an order to send the resident to the ER for evaluation and treatment; the nurse contacted EMS for transport to the hospital.
Further review of the EMR did not show any documentation of a written notice of transfer provided to R101 or his representative.
During an interview on 6/7/2024 at 7:10 pm, the DON stated she would expect that we follow the regulations.
During an interview on 6/7/2024 at 8:10 pm regarding the emergent transfer process, Licensed Practical Nurse (LPN) 6 stated We tell them [resident], and we call the family.
When specified if anything in writing was given to the resident or family, LPN 6 stated, No.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of the October 2023 RAI Manual page 2-24 showed: The ARD . must be set within 366 days after the ARD of the previous . comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous .
Quarterly . (ARD of previous .
Quarterly assessment + 92 calendar days).
Review of R58's electronic medical record (EMR) Face Sheet from the Face Sheet tab showed a facility admission date of 9/28/2022.
Review of the MDS assessments received by Centers for Medicare and Medicaid Services (CMS) showed the last MDS received had an assessment reference date (ARD) of 1/15/2024.
The MDS Coordinator (MDSC) provided documentation for R58 of .
Final Validation Report dated 5/30/2024 that the ARD of 4/11/2024 annual (comprehensive) MDS was not submitted until 5/30/2024 and, on page 4 of 52, showed Message: Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
During an interview on 6/6/2024 at 10:50 am, the MDSC confirmed R58's assessment was submitted late, stating, The assessment was closed, and the care plan signature was in there, but the last audit was not done to actually close it and I didn't notice it.
In a follow-up interview on 6/6/2024 at 6:12 pm, the MDSC stated the facility did not have a policy regarding timely submission of assessments.
She stated, We use the RAI Manual and follow that.
During an interview on 6/7/2024 at 7:00 pm, the Director of Nursing (DON) stated the expectation is that MDS assessments would be submitted within the RAI guidelines and confirmed the facility did not have a policy and used the RAI Manual.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
During a group interview on 6/6/2024 at 10:00 am, members of the Resident Council (R88, R15, R17,
conference and did not know that care plan conferences existed. R44 and R17 stated it would be important to them to be involved in planning their care. 4.
Review of R3's Record of Admission, located under the Clinical tab of the EMR), revealed R3 was admitted on [DATE] with diagnosis of cerebral palsy.
Review of R3's quarterly MDS with an ARD of 3/12/2024 located under the MDS tab revealed the resident did not have a BIMS score.
Review of R3's June 2024 Physician Orders, revealed the following order dated 9/21/2023: Bilateral body pillows to be in place under fitted sheet when resident in bed for torso support Resident having no upper body core strength and having gastric feeding tube in place resident needs for support in attempt to keep resident upright and aide in possible prevention of aspiration.
Review of the care plan dated 12/23/2020 revealed R3 had impaired bed mobility.
Interventions to care include assess for changes quarterly and as needed.
The care plan did not address the resident's order for body pillows under the fitted sheet.
Observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, revealed R3 was observed in bed without pillows under the fitted sheet.
During an interview on 6/6/2024 at 12:25 pm, MDS Coordinator (MDSC) stated she was currently working on the care plan conference process.
She revealed since COVID the facility has not had care plan conferences.
She said their new process would start today and they would be starting a Performance Improvement Plan (PIP) on this date.
The MDSC said usually when it is time for R56's care conference, they do not invite him, only his responsible party.
During an interview on 6/7/2024 at 2:15 pm, R97's Family Members (FM)1 and FM 2 stated they are rarely informed about the status of R97 and were uncertain about the process.
The family members indicated they would appreciate a care plan conference, so they would know more about what was going on with R97.
During an interview on 6/7/2024 at 3:35 pm, the Director of Nursing (DON) stated she was not aware that care plan conferences were not being conducted until R56 was discussed the day before.
She said moving forward care conferences will happen because they are important.
Cross Refer F-F684
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of the policy titled Physician Orders Policy and Procedure revised 6/2024, revealed the nurse will carry out all physician orders within a timely manner.
The nurse will notify the physician with any delay.
Review of R3's Record of Admission, located under the clinical tab of the electronic medical record (EMR), revealed R3 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy.
Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2024 revealed the Brief Interview for Mental Status (BIMS) was not completed.
The section to enter the BIMS was blank. It was documented the resident was rarely/never understood.
Review of R3's Physician Orders, revealed an order dated 9/21/2023 for bilateral body pillows to be in place under fitted sheet when resident in bed for torso support, resident having no upper body core strength, and having gastric feeding tube in place.
Resident needs support in attempt to keep resident upright and aide in possible prevention of aspiration.
Review of the Kardex Summary located in the EMR under the Clinical tab revealed for fall interventions bilateral body pillows in place under fitted sheet for torso support.
During observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, the resident was observed in bed without body pillows under the fitted sheet.
During an interview on 6/5/2024 at 5:16 pm, Certified Nurse Aide (CNA) 5 stated, he did not use pillows under the fitted bed sheet. He revealed he was not aware of the physician order to have pillows under the resident's fitted sheet.
During an interview on 6/5/2024 at 5:38 pm, Licensed Practical Nurse (LPN) 3 stated, she was not aware of the physician order for pillows under the fitted sheet and, she had never placed them under R3's sheet.
During an interview on 6/6/2024 at 11:10 am, LPN 5 confirmed she was aware of the physician orders for R3 to have pillows under his fitted sheet.
She stated she did not know why the pillows were not in place or when they were removed.
The LPN verified the pillows were not in place.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of the policy titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 2001, revealed the policy is to guide prevention of infection associated with Respiratory tasks and equipment.
Infection Control Considerations .
Medications: Number 3.
After completion of therapy: a. remove the nebulizer container; b. rinse the container with fresh tap water; c. dry on a clean paper towel or gauze sponge.
Number 4.
Reconnect to the administration set-up when air dried.
Number 5.
Take care not to contaminate internal nebulizer tubes.
Number 6.
Wipe the mouthpiece with damp paper towel or gauze sponge.
Number 7.
Store the circuit in plastic bag, marked with date and resident's name, between uses.
Review of R48's Record of Admission revealed R48 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD).
Review of the quarterly Minimum Data Set (MDS) for R48 with an Assessment Reference Date (ARD) of 4/25/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating resident was cognitively intact.
Review of June 2024 Physician Orders revealed the following order dated 2/14/2024 for ipratropium bromide-albuterol sulfa (Albuterol Sulfate/Ipratropium Bromide 3 milligrams/milliter-0.5 MG/3 ML solution) 1 vial inhalation twice daily for COPD.
Observation on 6/5/2024 at 1:17 pm, revealed R48's nebulizer medication chamber still had medication in it. It had not been rinsed and was not stored in the plastic storage bag.
Interview on 6/5/2024 at 2:44 pm, R48 stated staff placed the medication chamber and tubing in the basket behind her bed and did not rinse it out.
She revealed when she first received the device, the instructions indicated to boil the mouthpiece and medication chamber for five minutes after use.
Interview on 6/5/2024 at 2:52 pm, Registered Nurse (RN) 1 verified that medication was still in the medication chamber and, the medication chamber, mask and tubing were not bagged.
She stated she should have rinsed the medication chamber after the medication was administered, and the equipment should have been rinsed, dried, and placed in the plastic bag.
Interview on 6/5/2024 at 3:29 pm, the Director of Nursing (DON) stated the nurses administering the nebulized breathing treatments should wash the equipment after each use with soap and water, dry it with a paper towel, and then place the items in the storage bag.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
During an observation of R78's room on 6/4/2024 at 10:15 am, the bed had bilateral upper quarter rails in the up position.
During an interview on 6/7/2024 at 7:19 pm, the Director of Nursing (DON) stated the expectation was that the facility would attempt alternatives before side rails were used and that they do assess the resident; that risk/benefits would be advised, and it is documented who is being advised.
No signed consents were provided for any of the four residents above by the time of the exit conference.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
During an observation on 6/4/2024 at 9:15 am of the nursing staff posting on the wall in the lobby of the facility revealed a grid chart with all 30 days of June with the first three days filled out with the numbers of staff for each of the following staffing categories for each of three eight-hour shifts (days, evenings, nights - no ward clerk): *Registered Nurse (RN) *Licensed Practical Nurse (LPN) *Certified Nurse Aide (CNA) *Ward Clerk (WC) The staff posting did not show the name of the facility, the census for each shift, or the total number of hours for each category.
Review of the April and May 2024 staff posting documents provided by the facility showed the entire months and the number of staff for each category, but not the facility name, census, or total number of hours worked for each staffing category.
During an interview on 6/7/2024 at 9:33 am Human Resources (HR) staff stated she was responsible for the staff posting, and stated it may not be every day, the numbers are not the day of, but usually the day after. At 4:12 pm, the HR staff stated there was no policy regarding the nurse staff posting.
During an interview on 6/7/2024 at 7:03 pm, the Director of Nursing (DON) stated the expectation was that the staff posting would contain all the required elements.
The DON confirmed the posting did not contain all the required elements.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of the policy titled 10.b Medication Regimen Review revised 5/2020 revealed Procedure: A.
The consultant pharmacist will conduct medication regimen reviews (MRRs) if required under a pharmacy consultant agreement and will make recommendations based on the information available in the residents health record.
Review of the clinical record revealed was admitted to the facility on [DATE] with diagnosis of dementia.
The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment.
Section N revealed that the resident received antianxiety medications.
Review of the June 2024 Physician Orders revealed an order dated 5/9/2023 for lorazepam 0.5 milligrams (mg) tablet, one tablet by mouth as needed [PRN] TID [three times a day] for anxiety.
Review of R24's Medication Regimen Review (MRR) from 5/2023 through 5/2024 provided by the Director of Nursing (DON) did not reveal any recommendations from the pharmacist to address the lack of a 14-day stop date or for the physician to provide a rationale to continue the lorazepam.
Review of R24's EMR revealed no documentation by the resident's physician regarding the clinical rationale for continued use of lorazepam.
During a phone interview on 6/7/2024 at 10:47 am, Physician (PHY) 1 was contacted regarding the lorazepam order. He confirmed he did not document the rationale for the continued use of lorazepam.
During an interview on 6/7/2024 at 11:35 am, Licensed Practical Nurse (LPN) 1 stated they did not have any documentation showing pharmacy recommendations regarding the resident's lorazepam.
During an interview on 6/7/2024 at 11:47 am, the Pharmacist verified the monthly MRRs did not address the lorazepam and no recommendations were made.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
During further interview, the Pharmacist stated she
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Observation and interview on 6/6/2024 at 2:07 pm, the phlebotomy cart located at the nurses' station between the pink and green halls revealed one black top vacutainer tube that expired on 6/2/2024; one container (85 tubes) of light blue top vacutainer tubes expired on 12/31/2023. RN 1 verified the expiration dates and confirmed they were still available to be used.
- Observation on 6/6/2024 at 2:10 pm, the Green Hall medication cart was inspected with LPN 5 and
revealed one card of discontinued oxycodone (narcotic pain medication) 15 mg with 78 tablets was on the cart.
The LPN stated that discontinued narcotics should be removed from the cart the day they are discontinued. LPN 5 verified the oxycodone medication was discontinued.
Interview on 6/6/2024 at 2:20 pm, the DON stated expired medications should not be available for use on medication carts or in the medication room.
She stated they should be removed immediately.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Observation and interview on 6/7/2024 at 2:15 pm, family members (FM) 1 and FM 2 for R97 were
were not sure why.
They said that's too late for lunch, and R97 agreed.
Interview on 6/7/2024 at 6:54 pm, the DM said room trays are late because of the lack of communication between nursing and dietary staff. He said having a list of who is coming into the dining room would help with room trays being served earlier.
Interview on 6/7/2024 at 7:06 pm, the Director of Nursing (DON) stated the expectation is that meal service would be timely, all day should be timely.
Interview on 6/8/2024 at 11:27 am, License Practical Nurse (LPN) 4, the Unit Manager for Pink Hall and LPN 2, the Unit Manager for [NAME] Hall, stated they were not aware that meals were served as late as 2:00 pm at times.
They both agreed that receiving meals at 2:00 pm was too late and said serving a meal late impacts other resident care that staff need to complete.
A policy for meal service and/or mealtimes was requested.
The policy was never provided.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of a policy titled Abuse Reporting and Investigation, last revised March 2017 revealed Implementation: Number 3.c.
Interview the person(s) reporting the incident; d.
Interview any witnesses to the incident; e.
Interview the resident; f. and interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; g.
Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; i. interview other residents to whom the accused employee provides care or services; j. and review all events leading up to the alleged incident, and obtain the interviews in writing by the staff member or the administrator/abuse coordinator, notify the ombudsman, suspend the employee pending the progress/findings of the investigation.
Number 5.
Witness reports will be obtained in writing.
Number 14.
The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency.
- On 7/12/2023, an allegation of exploitation was reported to the Administrator regarding a staff to
resident personal relationship between CNA 1 and R71.
The Administrator failed to identify this personal relationship as potential exploitation and did not investigate or report this allegation.
Cross Refer F-F602
- On 3/8/2024, the Administrator was made aware of an injury of unknown origin for R71 and failed
to investigate and report this incident.
Cross Refer F-F609 and F-F610
- On 3/22/2024, the Administrator became aware of an allegation of employee to resident abuse
towards R78, perpetrated by CNA 2.
The Administrator did not identify this situation as abuse, did not protect R78 from CNA 2, failed to investigate this allegation, and failed to report the incident accurately.
Cross Reference F-F600 , F-F609 and F-F610
- On 4/22/2024 the facility became aware of an allegation of mental and verbal abuse from CNA 2 to
R107 and did not report or investigate the incident.
Cross Refer F-F600, F-F609, and F-F610 During an interview on 6/6/2024 at 9:20 am, the Administrator confirmed the incidents listed above were indicative of abuse to the residents, and were either not reported timely, and/or investigated thoroughly. He indicated he had misplaced the documentation related to the incidents.
115701 06/08/2024
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
Review of the policy titled Proper Use of Side Rails, revised in December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids.
General Guidelines: Number 13.
When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress used).
Review of the Nursing Home Inspection Report Upon Receipt of Equipment provided by the facility and completed annually, documented items inspected included electrical and bed function.
There was nothing noted regarding the review of the bed rails for secure attachment and/or gaps that the US
measurements for the bed rails to reduce the chance of resident entrapment when using bed rails.
During an interview on 6/7/2024 at 9:55 am, Maintenance Worker (MW) confirmed that they did not perform safety checks on resident beds with side rails.
Review of a resident list compiled by Restorative Nurse Aide (RNA) on 6/7/2024 at 8:05 pm revealed that 90 of 104 residents in the facility have one or two side rails on their beds.
During an interview on 6/7/2024 at 7:14 pm, the Director of Nursing (DON) stated the expectation was that maintenance would inspect the beds, including bedrails for safety and security.
Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.
Findings include:
Review of the facility policy titled Abuse Reporting and Investigation, revised March 2017, indicated the Statement Of Purpose is that all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by the facility.
Implementation: Number 1.
Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator and/or the Director of Nursing (DON), will appoint a member of management to investigate the alleged incident.
Number 14.
The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state and local laws, within five working days of the reported incident.
1.
Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admitted [DATE] with diagnoses of dementia and delusions.
Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 11 out of 15 which indicated R71 was moderately cognitively impaired.
115701
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115701 B.
Wing 06/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
- On 3/8/2024, the Administrator was made aware of an injury of unknown origin for R71 and failed to
investigate and report this incident.
Cross Refer
Review of the Nursing Home Inspection Report Upon Receipt of Equipment provided by the facility and completed annually, documented items inspected included electrical and bed function.
There was nothing noted regarding the review of the bed rails for secure attachment and/or gaps that the US Department of Health and Human Services: FDA guidelines dated 3/10/2006 that showed the measurements for the bed rails to reduce the chance of resident entrapment when using bed rails.
During an interview on 6/7/2024 at 9:55 am, Maintenance Worker (MW) confirmed that they did not perform safety checks on resident beds with side rails.
Review of a resident list compiled by Restorative Nurse Aide (RNA) on 6/7/2024 at 8:05 pm revealed that 90 of 104 residents in the facility have one or two side rails on their beds.
During an interview on 6/7/2024 at 7:14 pm, the Director of Nursing (DON) stated the expectation was that maintenance would inspect the beds, including bedrails for safety and security.
115701
Review of R3's Record of Admission, located under the clinical tab of the electronic medical record (EMR), revealed R3 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy.
Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2024 revealed the Brief Interview for Mental Status (BIMS) was not completed.
The section to enter the BIMS was blank. It was documented the resident was rarely/never understood.
Review of R3's Physician Orders, revealed an order dated 9/21/2023 for bilateral body pillows to be in place under fitted sheet when resident in bed for torso support, resident having no upper body core strength, and having gastric feeding tube in place.
Resident needs support in attempt to keep resident upright and aide in possible prevention of aspiration.
Review of the Kardex Summary located in the EMR under the Clinical tab revealed for fall interventions bilateral body pillows in place under fitted sheet for torso support.
During observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, the resident was observed in bed without body pillows under the fitted sheet.
During an interview on 6/5/2024 at 5:16 pm, Certified Nurse Aide (CNA) 5 stated, he did not use pillows under the fitted bed sheet. He revealed he was not aware of the physician order to have pillows under the resident's fitted sheet.
During an interview on 6/5/2024 at 5:38 pm, Licensed Practical Nurse (LPN) 3 stated, she was not aware of the physician order for pillows under the fitted sheet and, she had never placed them under R3's sheet.
During an interview on 6/6/2024 at 11:10 am, LPN 5 confirmed she was aware of the physician orders for R3 to have pillows under his fitted sheet.
She stated she did not know why the pillows were not in place or when they were removed.
The LPN verified the pillows were not in place.
115701
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115701 B.
Wing 06/08/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.