Summerhill Elderliving Home & Care
SUMMERHILL ELDERLIVING HOME & CARE in PERRY, GA — inspection on January 28, 2025.
Found 3 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 LPN CC's personnel file revealed a Licensed Practical Nurse Job Description.
The job description documented a position summary of an LPN which included that the LPN provides direct patient care under the supervision of a registered nurse.
The LPN contributes to patient care, provides a therapeutic environment, and is expected to abide by the standards, the job description, policies and procedures of the nursing department and hospital.
The job description also documented that one of the principle duties and responsibilities included administering medications and treatments utilizing the five Rights of Medication Administration and two patient identifiers.
Further review of LPN CC's personnel file revealed a Clinical Competency Testing evaluation.
The evaluation included that LPN CC had between mid-level and advanced-level experience with medication administration and advanced-level experience in a nursing home setting.
On 12/19/2024, a significant medication error occurred when LPN CC incorrectly administered another resident's medications to R2.
Further review revealed R2 was sent to the hospital emergency room for evaluation and admitted for observation due to polypharmacy and syncopial episode.
LPN CC documented in a written statement that on 12/19/2024, that she asked R2 if his name was R2 or R6's last name. R2 incorrectly stated R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for R6), which she documented resembled R2.
Her statement included that she administered R6's oral medications (to R2).
When she arrived at R6's room to administer medication to his roommate, she realized her error when R6 was lying in his bed and was wearing different clothing.
Further review of the facility's conclusion summary revealed that following the medication error on 12/19/2024, LPN CC was relieved of her medication cart at 11:50 am and subsequently sent home.
However, after being relieved of her medication cart on 12/19/2024 at 11:50 am, LPN CC then documented administering medications to R2, who was no longer in the facility.
115430
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 115430 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069
Review of clinical record for R2 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, cerebral atherosclerosis, atherosclerotic heart disease, hypertension, hyperlipidemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and vitamin D deficiency.
A review of the care plan dated 10/30/2020 revealed that R2 had a communication problem related to aphasia following cerebral infarction.
Further review of the care plan dated 1/16/2020 revealed interventions in place for licensed nursing staff to administer medications as ordered for cardiac prophylaxis, altered cardiovascular status, gastro-esophageal reflux disease, hyperlipidemia, depression, history of cerebral vascular accident and vitamin D deficiency.
However, on 12/19/2024, Licensed Practical Nurse (LPN) CC failed to administer the correct medications to R2 as care planned and ordered.
A review of facility investigation information including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/2024 conclusion summary, revealed that R2 received oral medications that were ordered for R6 on 12/19/2024 around 9:03 am. R2 was subsequently admitted for observation due to polypharmacy and a syncopial episode.
LPN CC documented in a written statement that on 12/19/2024, R2 was pushed (in his wheelchair) to the medication cart. LPN CC asked R2 if his name was R2 or R6's last name. R2 incorrectly stated R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for R6), which she documented resembled R2.
Her statement included that she administered R6's oral medications (to R2).
During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she was coming out of a meeting (on 12/19/2024) when LPN CC told her about the medication error. RN EE went to put her paperwork down on her desk and said she was going to call the Nurse Practitioner and check on R2. As RN EE rounded the corner to go that way, the CNA called out about R2 being on the floor.
When questioned why LPN CC asked R2 if his name was the last name of R2 or R6 (instead of just asking him what his name was), the DON stated that she did not know why LPN CC asked the question that way.
The DON stated that R2 jokes and can be silly. RN Supervisor EE stated that R2 was probably joking when he told LPN CC his name was R6.
115430
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 115430 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069
Review of the 10/11/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R1 was cognitively impaired and dependent on staff for ADL, including bed mobility.
Review of physician's orders revealed a corresponding physician's order, dated 1/22/2024, for padded bolsters to bilateral sides of the bed to define the bed parameters and bring a sense of security related to fear of falling from the bed.
The ADL self-care performance deficit care plan problem included an intervention, dated 1/25/2022, that documented R1 required total assistance from two staff to turn and reposition in bed.
There was also an intervention, dated 1/25/2022, that indicated R1 was not toileted.
She was incontinent of bowel and bladder, wore adult briefs, and was checked and changed.
Review of the Fall Risk Evaluation form, dated 10/9/2024, revealed that R1 was assessed as being at moderate risk for falls.
Review of progress notes revealed a 12/21/2024 6:28 am nurse's note entry that documented Licensed Practical Nurse (LPN) HH was notified by staff that R1 was observed on the floor. R1 was observed to be on the floor beside the bed with blood on the floor. R1 was responding normally to verbal and physical stimuli.
The nurse's note documented that R1 had a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas.
Hospice services, R1's family, and the physician were notified, and R1 was sent to the hospital emergency room for evaluation.
Review of the 12/21/2024 hospital emergency department physician documentation revealed that R1 sustained a 3-centimeter (cm) laceration to the right forehead and received three sutures to close the wound. A 12/21/2024 nurse's note at 2:47 pm documented that R1 had returned to the facility.
The resident had three sutures to the right side of the forehead and a dressing wrapped around her head.
115430
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 115430 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069