Chatuge Regional Nursing Home
CHATUGE REGIONAL NURSING HOME in HIAWASSEE, GA — inspection on June 8, 2024.
Found 4 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
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