SIGNATURE HEALTHCARE OF BUCKHEAD
LOCATED: 54 PEACHTREE PARK DRIVE N.E., ATLANTA, GA 30309
SIGNATURE HEALTHCARE OF BUCKHEAD was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents were provided with interventions and supervision to prevent repeat falls for 1 of 12 sampled residents (R4).
Resident (R4) sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization.
Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED].
Review of the 3/7/16 admission Minimum Data Set (MDS) assessment revealed the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) – meaning moderate cognitive impairment.
Closed record review for (R4) on 8/31/16 at 9:40 a.m. revealed upon admission the resident was assessed for falls and a care plan was generated on 3/9/16. Review of the care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party.
Review of the electronic skilled nurses’ notes with the Staff Development Coordinator (SDC) revealed a nurse’s note dated 3/23/16 timed at 4:15 p.m. indicating R4 who is a bilateral above the knee amputee was heard in her room screaming for help. A Certified Nurse Aide (CNA) went to R4’s room and alerted the nurse to come and assist because the resident had fallen and help was needed to get the resident off the floor. Review of a form in the closed record labeled Nursing Assessment dated 3/23/16 revealed the resident sustained [REDACTED]. The resident was seen by the facility’s physician and an X-ray was obtained with negative finding.
An updated plan of care dated 3/23/16 revealed the resident fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident’s wheelchair for proper functionality and keep items within reach. There was no documented evidence of determining the root cause of the fall or implementing other interventions to prevent future falls.
Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident’s wheelchair revealed he had a Maintenance Log Book kept at each nurses’ station. He said the Maintenance Book was checked frequently.
The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further reported most staff would simply tell him what needed to be fixed while passing in the hallways or elevator. When asked if he ever assessed a wheelchair on behalf of R4, he reported he remembered the resident when she was in the facility but did not recall a request to assess the wheelchair. He further stated he and the therapy department worked together on wheelchairs and he would double check the Maintenance Log Book.
On 9/1/16 at 12:40 p.m. the Maintenance Director reported he was never informed of a request to look at R4’s wheelchair and never assessed her wheelchair for proper functioning.
During an interview with the SDC on 9/1/16 at 10:30 a.m. she reported, according to the resident’s electronic record, the SBAR (Situation, Background, Assessment and Recommendation) note dated 4/5/16 timed 8:00 a.m. revealed the resident again fell from her wheelchair and sustained an injury. The resident was found in her room lying on the floor on her left side. Resident stated she finished brushing her teeth by the bathroom sink and was wheeling herself back to her table when she leaned forward too far and fell. Nurse’s notes revealed the resident’s injuries consisted of blood coming from her nose and a laceration noted on the bridge of her nose. A hematoma was noted above and around the resident’s left eye. Two staff assisted the resident from the floor into the bed and the bleeding stopped. The Nurse Practitioner was in the facility, assessed the resident and instructed staff to send the resident to the hospital for evaluation and treatment.
A detailed review of the hospital notes revealed the resident presented to the hospital per stretcher after her fall in the facility. According to the Emergency Physician notes dated 4/5/16, the resident had facial injury and bruising, left facial swelling and nose bleed. Results of Computed Tomography (CT scan) revealed mildly displaced fracture of the left orbital and medial wall. HemoSinus due to trauma, Left periorbital and frontal soft scalp tissue hematoma, Irregularity of the nasal bone and questionable age indeterminate nasal bone fractures. R4’s pain was documented in the ER as moderate. The ER physician described the findings as suspicious and documented his concern for the resident safety. The resident did not return to the Nursing Center according to the closed record. She was discharged home from the ER with family and home health on 4/5/16.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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