SAVANNAH, GA- THUNDERBOLT CARE CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observations, resident and staff interviews, and record review, the facility failed to promote care in a manner that maintained or enhanced each resident’s dignity and respect by not referring to dependent residents who require assistance with meals as feeders in the resident presence for one of 52 sampled residents (R) (R58).

Allow residents to self-administer drugs if determined clinically appropriate

Based on observations, resident and staff interviews, record reviews, and review of the facility’s policy titled, Resident Self-Administration of Medication, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 52 residents (R) (R36). This deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors.

Reasonably accommodate the needs and preferences of each resident.

Based on observations, staff interviews, record review, and review of the facility’s document titled Room Changes, two policies: titled, Facility Care Center Policy and Dementia Care, the facility failed to ensure six of 16 residents (R), (R36, R37, R48, R58, R101, and R108) were assessed for placement on the Memory Care Unit. This deficient practice had the potential to prevent residents from receiving care that accommodated their individual care needs.

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations and staff interviews, the facility failed to maintain adequate and comfortable lighting levels in one corridor with six rooms in the [NAME] wing. The census was 126 residents.

Honor the resident’s right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on observation, record review, interviews, and review of the facility’s policy titled Resident and Family Grievances, the facility failed to ensure their grievance procedures were followed for one of one resident (R) (R73) reviewed for grievances of 52 sampled residents.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Based on record review, staff interviews, and review of the facility policy titled Transfer and Discharge (Including AMA), the facility failed to provide the resident/family with a written explanation of reason for a transfer to an acute care hospital for three of four residents, (R) (R37, R73, and and R573).

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Based on record review, staff interviews, and review of the facility policy titled Bed Hold Prior to Transfer, the facility failed to ensure that three of four residents, (R) (R37, R73, and R573) were made aware of the facility’s bed-hold and reserve bed payment policy before and upon transfer to a hospital from the facility.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Based on observations, record review, interviews, and a review of the facility’s policy titled Comprehensive Care Plans, the facility failed to develop and implement person-centered comprehensive care plans for one of 53 sampled residents (R) (R36). Specifically, failed to implement a care plan for nutritional intake for R36.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on observations, staff and resident interviews, record review, and review of the facility’s policies titled Activities of Daily Living (ADLS), and Nail Care, the facility failed to provide care relating to activities of daily living (ADLs) for four of 53 residents sampled residents (R) ( R69, R100, and R101, R113). This deficient practice had the potential to cause risk for unmet needs, a diminished quality of life for residents.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on observations, interviews, and record reviews the facility failed to follow dietary orders for one resident (R) (R572) of 53 sampled residents. Specifically, R572 was on a puree diet but was provided a sandwich on [DATE] which resulted in her choking death.

It was determined that the provider’s non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Quality of Care, F684, at a scope and severity of J.

The IJ began on [DATE], R572 choked after receiving and eating a sandwich. Evidence of the eaten
sandwich included the paper that the sandwich was wrapped in and a small portion of the bread remaining in front of the resident. The Heimlich maneuver was attempted but was unsuccessful resulting in cardiac arrest and death in the facility.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observations, residents and staff interviews, record review, and review of the facility policies titled Accident and Supervision, Oxygen Safety, and Resident Rights-Smoking, the facility failed to ensure a safe and secure environment free for residents and staff for three of 53 sampled residents (R) (R9, R73, R96).

Specifically, failed to ensure failed to ensure one resident (R ) (R9) had secured oxygen cylinders, one resident (R73) was provided with safety equipment during transfer, failed to ensure one resident (R96) was assessed for safe smoking. This failure had the potential to create risks for the safety and well-being of the residents, staff, and visitors in the building. The census was 126.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observations, staff interviews, record reviews, and the facility policy titled Catheter Care, the facility failed to ensure that one of four residents’ (R) (R36) catheter tubing was not coiled and correctly positioned to prevent obstruction of urinary flow. In addition, the facility failed to ensure R36’s drainage bag was covered and secure (not dragging the floor) underneath the resident’s wheelchair. This deficient practice had the potential to put residents at risk for complications related to urinary health and with the possibility of urinary tract infections.

Provide safe and appropriate respiratory care for a resident when needed.

Based on observation, record review, staff interviews, and review of the facility policy titled Oxygen
Concentrator, the facility failed to follow physician orders related to oxygen administration for one of one resident (R) (R42) reviewed for receiving oxygen.

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Based on record review and staff interviews, the facility failed to ensure residents were seen by a physician in the facility at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, that one of 52 residents (R) (R69) was seen in a timely manner by their primary physician.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observations, staff interviews, and a review of the facility’s policy titled Medication Storage, the facility failed to secure medications, maintain a lock on medication and treatment carts, ensure refrigerated medications were stored in the refrigerator with appropriate humidity level, and dispose of expired medication for three of five medication carts, one of two treatment carts, and one of two medication rooms. This deficient practice had the potential for staff to administer unsafe medications and biologicals and to use expired items for care. The facility census was 126 residents.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations, record review, staff interviews, and review of the facility’s policy titled Food Safety, the facility failed to record food temperatures that could potentially affect all residents receiving an oral diet. The facility census was 126.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Based on observations, interviews, record review, and review of Job descriptions for the Administrator and Director of Nursing (DON), the facility administration failed to ensure dietary orders were followed after R572 choked on a sandwich on [DATE] which resulted in her death. The facility also failed to follow up with the investigation of circumstances leading to R572’s choking death.

It was determined that the provider’s non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Administration, F835, at a scope and severity of J.

Provide and implement an infection prevention and control program

Based on observations, staff interviews, record review, and review of the facility’s policies titled Infection Prevention and Control,, Hand Hygiene, and Wound Treatment Management, the facility failed to ensure an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced infection control standards for four residents ( R) (R16, R69, R35, and R60), related to medication administration (R16), wound care (R69), respiratory equipment storage (R35 and R60), clean and dirty carts (East and [NAME] wing), and the Water management program. This deficient practice had the potential to cause the spread of infection throughout the facility. The census was 126.