NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER
LOCATED: 1500 S JOHNSON FERRY ROAD, ATLANTA, GA 30319

NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER 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 SERVICES PROVIDED BY THE NURSING FACILITY MEET PROFESSIONAL STANDARDS OF QUALITY.

LEVEL OF HARM –ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview it was determined that the facility failed to provide professional quality of care for one (1 ) resident (R1) of the seven (7) sampled who suffered a fractured femur by not reporting an x-rays report to the physician correctly for additional intervention.

This caused actual harm to R1 for nine (9) days at which time the resident was transferred to an acute care facility.

Findings include:

Review of the Medical Record for R1 revealed nurses notes dated February 3, 2016, indicating that Certified Nursing Assistant (CNA) AA was assisting R1 to transfer from the wheelchair to the toilet, when the R1 became weak and had to be lowered to the floor. AA then notified the LPN, BB to help her with R1. BB found R1 on the floor. At that time they assisted R1 from the bathroom floor into the wheelchair. The Medical Doctor (MD) and Responsible Party (RP) were notified.

Further Medical record review revealed that R1 complained of right hip pain the next morning on 02/04/16, after receiving regularly scheduled pain medication of [MEDICATION NAME] – [MEDICATION NAME] 5/325 mg and an as needed dose of pain medication.

Further Medical Record Review revealed nurses note dated 02/04/16, resident complained of pain to the right hip due to fall from yesterday. Right hip noted to be swollen X-ray of the hip ordered.

A new order was received for an x-ray of the hip was ordered and was obtained on 02/04/16 and was subsequently reported from the nursing staff to the Medical doctor (MD) to be negative for any fractures.

However, review of the Mobilex Radiology report dated 02/08/16 revealed, stamped POSITIVE. Two x-ray reports noted on one page. On the upper page radiology report for knee 1-2 views (right) and on the lower half of the page radiology report results for Tibia/Fibula. The upper Knee report is noted to read:

Results: Fracture lucency of the distal tibial shaft. Soft tissue swelling. No gross malalignment. Conclusion: Acute distal femoral shaft, incompletely visualized with single view. Consider full exam when able.

The Radiology report on the lower half of the page is noted to be for the Tibia/Fibula and reads:

Tibia/Fibula (Right) Conclusion: No acute osseous abnormality. [MEDICAL CONDITION] changes.

Further Medical Record review revealed nurses note for R1 dated 02/15/16, for a urine analysis was ordered. Review of a Nurses noted on 02/16/16 at 11:51 a.m. revealed the resident appears confused, altered mental status, involuntary jerking, shaking and left facility via stretcher to local acute care hospital. MD and RP notified.

Interview on 03/01/16 at 1:00 p.m. with Licensed Practical Nurse (LPN) DD while reviewing the x-ray report of the knee dated 02/08/16, DD stated she does not know what fracture lucency means. DD stated that, incompletely visualized with a single view meant that additional x-rays should have been done, but were not done.

Interview on 03/01/16 at 1:13 p.m. with the Director of Nursing (DON). While reviewing the x-ray report for R1 ‘ s knee the DON stated she was not sure what fracture lucency meant but stated according to the conclusion on the radiology report of the knee that the x-ray was inconclusive and that R1 needed additional x-rays, that were not done. The DON stated her expectations of her staff are that when radiology reports are received that read: incompletely visualized consider a full exam, then she expected the nurses to call the physician and read the physician the entire report, not just a portion of the report, and ask the physician for an order for [REDACTED].

Interview on 03/01/16 at 1:13 p.m. with the Director of Nursing (DON). While reviewing the x-ray report for R1 ‘ s knee the DON stated she was not sure what fracture lucency meant but stated according to the conclusion on the radiology report of the knee that the x-ray was inconclusive and that R1 needed additional x-rays, that were not done. The DON stated her expectations of her staff are that when radiology reports are received that read: incompletely visualized consider a full exam, then she expected the nurses to call the physician and read the physician the entire report, not just a portion of the report, and ask the physician for an order for [REDACTED].

Interview on 03/03/16 at 2:00 p.m. with J revealed that I don ‘ t know what happened on 02/03/16, whether R1 was lowered to the floor of if she fell ; however the surgeon told me that R1’s femur bone was shattered. J stated that the facility did not call him/her with the x-ray results for the x-rays obtained on 02/08/16.

Interview on 03/03/16 at 2:08 p.m. with MD revealed that he/she usually visits the resident every couple of weeks. MD stated that when the nurse called him on 02/08/16, regarding the x-ray report that was received on 02/08/16, that the nurse told him/her that there was no osseous abnormalities. MD stated that a few days after the nurse called him with the x-ray report.

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

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