ELBERTON, GA- HEARDMONT HEALTH AND REHABILIATION

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

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

Based on interviews, record review, and review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure that four of 19 sampled residents (R) (R8, R14, R17, and R18) were free from physical, verbal, and sexual abuse. The allegations of abuse are identified to have been committed by R3, R5, and a Contracted Facility Staff.

On 12/5/2023, 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.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview, record review and review of policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure allegations of sexual, physical and verbal abuse, were reported to the State Agency (SA) in a timely manner for four of 19 sampled residents (R) (R8, R14, R17 and R18). The allegations of abuse are identified to have been committed by R3, R5, and a Contracted Facility Staff.

On [DATE], 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.

The facility’s Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy’s (IJ) on [DATE] at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE] when the facility failed to protect four residents (R8, R14, R17, and R18) from physical, verbal, and sexual abuse.

Respond appropriately to all alleged violations

Based on interview, record review and review of policy titled Abuse Prohibition Policy and Procedures, the facility failed to investigate, correct, and prevent allegations of abuse for four of 19 sampled residents (R) (R8, R14, R17, and R18) with multiple documented incidences of physical, sexual, and verbal abuse by R3, R5, and a Contracted Physical Therapist.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Based on interviews, record review and review of the policy titled Transfer or Discharge Notice, the facility failed to provide the required information in writing to the resident and/or representative and failed to document in the medical record the rationale for the facility-initiated transfer/discharge for two of three residents (R) (R2 and R10) sampled for transfer/discharge.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Based on interview, record review and review of the policy titled Bed-Holds and Returns, the facility failed to allow one of three residents (R) (R2) reviewed for transfer/discharge to return to the facility after a facility-initiated transfer to the hospital for behavior evaluation, in which the hospital determined the resident did not pose a danger to himself or others.

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 review of the policy titled Care Plans, Comprehensive Person-Centered the facility failed to develop and implement the person- centered care plan that focused on risks for wandering and elopement for two residents (R) (R6 and R10) from a sample of 19 residents.

On 12/5/2023, 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.

The facility’s Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy’s (IJ) on 12/5/2023 at 3:45 pm. The second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped in a three-month timeframe.

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

Based on observations, interviews, record review, and review of the facility policy titled Elopements, the facility failed to provide adequate monitoring and protective oversight of the elopement prevention program and failed to ensure the mechanisms of the electronic alert system was functioning properly to prevent residents at risk for elopement to exit the facility undetected. In addition, the facility failed to have a process in place for the four remaining exit doors not equipped with the electronic alert system. Specifically, resident (R) R6 and R10, both wearing electronic alert system devices, eloped from the facility for approximately three hours, before being spotted by local citizens, and reported to the facility that they were missing. The sample size was 19.

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, interview, and review of the policy titled Storage of Medications, the facility failed to ensure medical supplies and medications for wound care were securely stored in the treatment room. The treatment room door did not have a locking mechanism to the doorknob. Additionally, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, and failed to discard expired biologicals and medical supplies prior to expiration date in the treatment storage room. The facility census was 45.

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

Based on interviews, record review and review of the Administrator’s Job Description, Administration failed to protect residents from abuse, failed to report allegations of abuse, and failed to thoroughly investigate allegations of abuse. In addition, Administration failed to provide protective oversight of the facility environment including adequate supervision for wandering residents and ensuring proper functioning of the electronic alert system. Two Immediate Jeopardy situations were identified when abuse and allegations of abuse for four residents (R8, R14, R17, and R18) were not reported to the State Agency (SA); and 10 allegations of abuse were not thoroughly investigated; and two residents (R) (R6 and R10) eloped four times in a three-month period; The sample size was 19.

On 12/5/2023, 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.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on interview, record review and review of the policy titled Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure the QAPI program effectively identified, developed and implemented appropriate action plans to meet the needs of six of 19 sampled residents (R) (R6, R10, R8, R14, R17, and R18). Specifically, the Quality Assurance Performance Improvement program failed to protect R8, R14, R17, and R18 from abuse and failed to provide safety and oversight of the elopement prevention
program for R6 and R10.

On [DATE], 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.