ATLANTA, GA- BUCKHEAD CENTER FOR NURSING AND HEALING

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, staff interviews, record review and review of the facility policy titled, Resident Rights and Dignity Management, the facility failed to promote, maintain, and protect a resident’s dignity for one of three residents (R#29) with a urinary catheter.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interviews, record review, and review of the facility policy titled Notification of Changes, the facility failed to notify the resident representative of a significant change in condition for two of 32 sampled residents (R) (R#20 and R#24).

On 2/4/22, the facility failed to notify R#20’s representative of an increase in the resident’s mood and behaviors and failed to notify the resident’s representative of the resident signing an Against Medical Advice (AMA) discharge form and exiting the facility. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was not able to make safe decisions about signing out AMA.

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, staff interviews, and review of the facility policy titled, Maintenance Service, the facility failed to maintain a clean, comfortable, homelike, environment on two of four floors (third and fourth floors).

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on staff interviews, resident representative interviews, record review, and review of the facility policies titled Abuse, Neglect and Exploitation, Transfer and Discharge (including AMA), and Notification of Changes, the facility failed to protect one of 32 sampled residents (R) (R#20) from neglect by not ensuring the resident’s cognitive level and mental status was appropriate for him to make an informed decision to discharge by signing an Against Medical Advice (AMA) form and exiting the facility. On 2/4/22, R#20 was allowed to sign an AMA form and then exited the facility without the knowledge or assistance from his representative or a discharge plan in place. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was unable to make safe self-care decisions.

On 7/13/23, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

Prepare residents for a safe transfer or discharge from the nursing home.

Based on staff interviews, resident representative interviews, record reviews, and the facility policy titled Transfer and Discharge (including AMA), the facility failed to ensure one of 32 sampled residents (R) (R#20) had an appropriate discharge by ensuring the resident’s cognitive level and mental status was appropriate for him to make an informed decision for self-discharging by signing an Against Medical Advice (AMA) form and exiting the facility.

On 7/13/23, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

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, interviews and record review, the facility failed to develop/implement/update the care plan for three of 32 sampled residents (R) (R#17, R#29, and R#28).

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

Based on observation, record review, staff interviews, and facility’s policy titled Medication Administration, the facility failed to follow Physician Orders for four of 32 sampled residents (R) (R#17, R#6, and R#18) related to (1) trach care and tracheal suctioning for R#17; (2) providing wound care for R#6; and (3) providing medications for R#18.

Provide appropriate foot care.

Based on interviews, observations, record reviews and policy titled Podiatry Services, the facility failed to provide podiatry services to four of 32 sampled residents (R) (R#1, R#6, R#12, and R#21) as evidenced by long, curling, jagged, thick toenails.

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

Based on observation, interviews, record review, and review of the facility policies titled, Resident
Self-Administration of Medication and Notification of Changes, the facility failed to ensure that care was provided in accordance with professional standards of practice for three of 32 sampled residents (R) (R#38, R#21 and R#25) related to (1) ensuring that medications were not left at the bedside for R#38 and (2) falls and accident hazards for R#21 and R#25.

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 observation, record review, staff interview, and review of the facility policy titled Catheter Care, Urinary the facility failed to obtain a Physician Order for the use of an indwelling urinary catheter for one of 10 residents (R) (R#29) with an indwelling urinary catheter.

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Based on interviews, observation, record review, review of the Facility Assessment, and review of the facility’s policy titled Colostomy/Ileostomy Care the facility failed to provide the correct size colostomy bags for three of four sampled residents (R) (R#6, R#12, and R#29).

Provide enough food/fluids to maintain a resident’s health.

Based on record review, staff interviews, and a review of the facility’s policy titled, Weight Policy, the facility failed to maintain acceptable parameters of nutritional status, to include body weight, for one of three residents (R) (R#28) reviewed for weight loss.

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

Based on observations, record review, review of the facility policy titled Tracheostomy Care and staff interviews, the facility failed to perform Tracheostomy (trach) care according to professional standards for one of three sampled residents (R) (R#17).

Provide safe, appropriate pain management for a resident who requires such services.

Based on record review, resident and staff interviews, and review of the facility policy titled Pain
Management, the facility failed to follow the Physician Order for one of 32 sampled residents (R) (R#12) related to the administration of a pain medication.

Obtain a doctor’s order to admit a resident and ensure the resident is under a doctor’s care.

Based on staff interviews, resident representative interviews, record reviews, and the facility policy titled Transfer and Discharge (including AMA), the physician failed to assess one of 32 sampled residents (R) (R#20) to ensure the resident’s cognitive level and mental status was appropriate for him to make an informed decision for self-discharge by signing an Against Medical Advice (AMA) form and exiting the facility.

On 2/4/23, the resident was allowed to sign an AMA form and then exited the facility without the knowledge or assistance from his representative or a discharge plan in place. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was unable to make safe self-care decisions.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on record review and interviews, the facility failed to ensure that medications were obtained from the pharmacy in a timely manner for two of 32 sampled residents (R) (R#6, and R#12).

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 observation, interviews, and review of the facility policy titled Medication Storage, the facility failed to ensure medications were dated appropriately when opened to determine the discard date in two of six medication carts (300 Hall Top Medication Cart and 300 Hall Bottom Medication Cart).

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Based on observation, record review, and staff interview, the facility failed to provide bedtime snacks for three of 32 sampled residents (R) (R#12, R#13, and R#16).

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

Based on record review, review of the Nursing Home Administrator and Director of Nursing (DON) job descriptions, and staff interviews, the facility administration failed to effectively oversee the facility’s discharge process resulting in an unsafe discharge for one of 32 sampled residents (R) (R#20).

On 7/13/23, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

Provide and implement an infection prevention and control program

Based on observation and staff interviews, the facility failed to maintain an effective infection control program for one of three residents (R) (R#17) reviewed for tracheostomy (trach) care related to failure to utilize proper technique.