Hartsville Convalescent Center
HARTSVILLE CONVALESCENT CENTER in HARTSVILLE, TN — inspection on August 11, 2025.
Found 1 citation. 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
jeopardy to resident health or safety
care planned interventions if indicated to decrease the risk of elopement (TAB IDT Clinical Meetings Book).
Beginning 11/28/24 the DON &/or Nursing Supervisor will monitor the visits of the assessments are conducted by the Psych NP for Resident #1 to ensure treatment and care is provided post elopement (Tab # 4).
Elopement drills were conducted by Administrator and Nursing Supervisor monthly for 3 months beginning 12/2/2024 as verified by written reports. (TAB# 16).
The Director of Nursing changed the monitoring of Wander guard bracelets from weekly to every shift on the Resident's Medication Administration Record beginning 12/2/24 (Tab# 19).
Beginning 12/2/24 the Administrator will monitor the compliance of entering and exit of the front door changes during the Morning Stand-up meeting.
Any non-compliance or violation of the front door signage or changes will be addressed immediately and document each violation on an investigation form (See Stand-up Meeting minutes).
Beginning 12/2/24 the Nursing Supervisor will review the education delivered to all staff and confirm all staff have been educated, including Agency staff.
The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. A one hundred percent of all education sign-in sheets will be reviewed by nursing supervisor &/or DON to ensure that all staff have been properly educated related to the Elopement and Wandering Resident policies and Interventions communicated.
The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. 4) How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Ad Hoc QAPI meetings were held weekly times 2 weeks beginning 12/3/24 to review the action plan and needed changes and the monthly QAPI meeting was conducted the last week of December. At the OAPI meetings the results of all monitoring by the DON, nursing managers, and Administrator will be reviewed, however any concerns identified will be addressed as discovered, including any needed education and/or progressive discipline. At the December meeting the DON, Nursing Managers, and Administrator will report monitoring outcomes of in-services, care plans, IDT meetings, and Stand-up meetings, at the monthly OAPI Committee meetings.
The Administrator will report to the Owner the monitoring outcomes on a monthly basis.
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