TUCKER, GA- MEADOWBROOK HEALTH AND REHAB

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

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

Based on resident and staff interviews, and record review, the facility failed to protect the resident’s right to be free from verbal and physical abuse by another resident by failing to report an allegation of verbal and physical abuse to the State agency between two of 27 sampled Residents (R) (R#11 and R#161) reviewed for abuse.

Ensure each resident receives an accurate assessment.

Based on staff interviews and record review, the facility failed to ensure the accuracy of a significant change Minimum Data Set (MDS) for one of 27 sampled residents (R) (R#42). This failure had the potential to affect the quality-of-care for R#42.

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

Based on record review, staff interviews, and review of the facility’s policy titled, Comprehensive Care Plans, the facility failed to develop a comprehensive care plan for resisting care and wound care for one of 27 sampled residents (R) (R#42).

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

Based on observations, staff interviews, and record review, the facility failed to ensure that one of five residents (R) (R#21) reviewed for Activities of Daily Living (ADL) received incontinent care. Sample size was 27 residents. The deficient practice had the potential for R#42 to develop pressure sores, and/or worsen ongoing pressure sores.

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

Based on staff interviews, record review, and review of the facility policy titled, Accidents-Elopement, the facility failed to prevent elopement out of the building and into the parking lot of one of one resident (R) (R#311) reviewed for elopement out of a total sample of 27 residents.

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

Based on observations, staff interviews, record review, and review of facility policy titled, Oxygen
Administration, the facility failed to provide safe oxygen (O2) administration for three of four residents (R) (R#11, R#14, and R#21) receiving O2 therapy from a total sample of 27 residents. The deficient practice had the potential of the residents receiving inadequate O2 therapy.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Based on resident and staff interviews, record review, and review of the facility’s policy titled, Dialysis, Care for a Resident, the facility failed to be in communication and collaboration with the dialysis facility regarding dialysis care and services for one of 27 sampled residents (R) (R#211).

Ensure medication error rates are not 5 percent or greater.

Based on observation, staff interviews, record review, and review of facility policy titled, Administering Medication, the facility failed to ensure a medication error rate below five percent. During medication administration five medication errors for resident (R) (R#71) were made from 30 opportunities. The medication error rate was 16.66 percent.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on staff interviews, record review, and review of the Physicians Orders for Life Sustaining Treatment (POLST), Guidance for Completing the POLST Form, the facility failed to ensure resident medical records were complete for two of seven residents (R) (R#7 and R#39) related to POLST forms not signed by the resident/resident representative and/or the physician resulting in the POLST forms not being completed.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Based on observations, staff interview, and review of the facility’s policy titled, Inspection of
Heat/Air-conditioning Systems, the facility failed to ensure that heat/air-conditioning systems located on one of four nursing units were in good repair. The deficient practice had the potential to affect the safety, functional, and sanitary conditions for residents on a secured unit.