Cambridge Post Acute Care Center
CAMBRIDGE POST ACUTE CARE CENTER in SNELLVILLE, GA — inspection on July 9, 2024.
Found 2 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
Findings included:
A review of the undated policy titled Pharmacy Services, revealed the facility will provide Pharmacy Services in accordance with state and federal regulations.
Procedure: Number 5.
The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biological to meet the needs of each resident.
Review of the policy titled Medication Delivery Expectations dated April 2022, revealed the policy is to ensure all residents will receive their medications as ordered and to ensure if medications are not received, center immediately intervenes, and medications received within 4 hours.
Protocol: A.
Notify the pharmacy of medication that has not been received.
Pharmacy has someone on call 24 hours a day, so it is never acceptable to document that a medication is 'not available.' It is the center's responsibility to ensure medications are administered. D. If medication is not available, call the pharmacy and request medication to be delivered STAT [as soon as possible] either from your facility pharmacy or community back-up pharmacy. H.
Notify the physician if medication will be given late or obtain an order for different start times, if appropriate.
1. A review of the clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diastolic congestive heart failure (CHF) and asthma.
A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2024, revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated she was cognitively intact.
A review of the June 2024 Medication Administration Record (MAR) revealed the following medication orders:
1.
Xopenex Inhaler two puffs every six hours related to COPD ordered 5/11/2024.
According to the June 2024 MAR, the inhaler was not administered (as indicated by the code 13) eight times, and on two occasions, at 6:00 pm, the documentation was left blank.
2.
Atorvastatin 40 milligrams (mg) one tablet at bedtime for elevated cholesterol ordered 3/1/2024.
According to the June 2024 MAR, the Atorvastatin was coded as 13 which indicated not administered eight times.
115771
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 115771 B.
Wing 07/09/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078
Findings included.
Review of the policy titled, Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, dated 8/2022 revealed it is the policy of the facility to ensure that the residents receive Influenza, Pneumococcal, and SARS-CoV-2 immunizations, in accordance with state and federal regulations, and national guidelines.
Pneumococcal Immunization: Number 1.
Pneumococcal immunization status will be determined and documented for each resident upon admission.
Number 5.
The resident's medical record includes documentation that indicates, at a minimum, the following:
i.
That the resident or resident representative was provided education regarding the benefits and potential side
effects of pneumococcal immunization
ii.
That the resident either received the pneumococcal immunization or did not receive the pneumococcal
immunization due to medical contraindications or refusal.
Review of the clinical record revealed R18 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and dementia.
Review of the annual Minimum Data Set (MDS) assessment dated with an Assessment Reference Date (ARD) of 4/2/2024 revealed R18 had a Brief Interview of Mental Status (BIMS) score of 0.
Review of the Immunizations tab in the electronic medical record (EMR) revealed no documentation that R18 was administered the pneumonia vaccine since admission.
Review of the Miscellaneous tab in the EMR revealed no documentation that a refusal to consent to the pneumonia vaccine was filed in the EMR.
Interview on 7/1/2024 at 12:40 pm, the Infection Control Preventionist (ICP) revealed information regarding resident immunizations is the responsibility of the Unit Managers (UM).
The ICP stated, I don't do anything with this, it's the Unit Managers responsibility.
During further interview, the ICP stated the UM's ensure the residents vaccination status is determined and documented in the medical record.
115771
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 115771 B.
Wing 07/09/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Cambridge Post Acute Care Center 2020 McGee Road Snellville, GA 30078