PRUITTHEALTH – CRESTWOOD
LOCATED: 415 PENDLETON PLACE, VALDOSTA, GA 31602

PRUITTHEALTH – CRESTWOOD 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 THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS.

LEVEL OF HARM – IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review, facility investigation summary review, facility Entity Reported Incident Intake review, facility Behavior Management Program Policy review, facility Behavior Management Documentation Form review, staff written statement review, and staff interview, the facility failed to provide supervision in response to verbal threats and aggression exhibited by one (1) resident (Resident #1), who made multiple verbal threats of harm against another resident (Resident #2), to thus ensure the safety of Resident #2. After facility admission, Resident #1 exhibited aggressive behaviors toward staff, including hitting staff and pulling staffs’ hair. Interventions were developed to address Resident #1’s behavior, and the resident was placed on a Behavior Management Program on 09/09/2014. Documented evidence then indicated that Resident #1 had no behaviors observed/reported daily from 10/01/2014 through 10/21/2014, at which time she was discontinued from the Behavior Management Program. The physician documented in a Physician’s Progress Note of 10/28/2014 that Resident #1’s mood, Bipolar Disorder, and Schizophrenia were stable. The facility, however, failed to notify Resident #1’s physician of the resident’s ongoing refusal of drug therapy, including her Risperidone antipsychotic drug therapy, during October of 2014. On 11/02/2014, Resident #1 experienced a change in behavior and was reported by facility staff to have made multiple verbal threats against Resident #2, including If you don’t get her, I am going to get her, and I’m going to get that b—h. However, even though these verbal threats against Resident #2 represented a change in behavior for Resident #1, the facility failed to put measures into place to ensure close monitoring of Resident #1, failed to place Resident #1 in the Behavior Management Program as specified by facility Policy, and failed to notify Resident #1’s physician of the aggressive behavior and verbal threats. Then, on 11/11/2014, facility staff discovered Resident #2 not breathing and having no pulse, and with an electric bed cord around her neck. Resident #1 was documented as stating to facility staff that she had killed Resident #2, and Resident #1 was later arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility’s noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility’s Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she had killed her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1’s verbal threats against Resident #2.

Continuing: During an interview with the Administrator conducted on 11/19/2014 at 2:30 p.m., the Administrator acknowledged the 11/02/2014 incidents during which Resident #1 made verbal threats against Resident #2, further stating that as a result of Resident #1’s 11/02/2014 verbal threats toward Resident #2, staff administered (the antianxiety drug) Ativan intramuscularly to Resident #1, and also redirected the two residents. The Administrator acknowledged, however, that the administration of Ativan to Resident #1 and the redirection of these residents were interventions in place prior to the 11/02/2014 incidents involving Resident #1 making verbal threats against Resident #2, and further acknowledged that no new measures had been developed in response to Resident #1’s aggressive behavior involving verbal threats on 11/02/2014.

Personal Note from NHAA 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 can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

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