Citations in Georgia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Georgia.
Statistics for Georgia (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Georgia
Latest Citations in Georgia
Surveyors found that expired syringes were not discarded as required, with a sealed bag of expired syringes discovered in the medication storage room. The RNS confirmed the syringes were expired and had not contacted the pharmacy for guidance, while the DON removed the label and sought clarification using the lot number. The pharmacy's DCS was still awaiting manufacturer confirmation on the expiration status, highlighting a lapse in following medication storage and labeling policy.
Health shakes stored in nourishment room refrigerators on two floors were not labeled with the date they were removed from the freezer, as required by facility policy and manufacturer instructions. Both the Dietary Manager and Registered Dietitian confirmed that the shakes must be used within 14 days of refrigeration, but no documentation was present to ensure compliance.
A nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while administering medication and nutrition via a feeding tube to a resident with significant medical needs. Although gloves were used, the omission of a gown was contrary to facility policy and was later acknowledged by both the LPN and the DON.
Staff did not ensure privacy for two residents with indwelling urinary catheters, as their catheter drainage bags were observed without required privacy covers, leaving urine visible to others. Both residents had little to no cognitive impairment and required catheter care per facility policy, which mandates privacy bags at all times. Staff interviews confirmed awareness of the policy and the expectation for privacy covers.
Staff did not ensure resident bathrooms were kept clean and sanitary, as evidenced by the presence of brown substances, soiled items, and strong odors of urine and feces in multiple restrooms. Housekeeping and CNA staff had unclear responsibilities for cleaning bodily fluids, resulting in unsanitary conditions despite facility policy requirements.
A resident was transferred to a hospital without receiving the required written bed hold notice, as confirmed by both an LPN and the DON. Facility policy mandates that this information be provided at the time of transfer, but no documentation was found in the resident's records to show compliance.
A resident with a history of urinary tract infection and heart failure had an indwelling urinary catheter placed following a verbal physician order, but the order was not transcribed into the electronic medical record as required by facility policy. Observations confirmed the catheter was in use, and an LPN acknowledged the omission. The DON stated that staff are expected to document and transcribe physician orders directly into the electronic health record.
A resident with chronic respiratory conditions did not receive oxygen therapy at the prescribed flow rate, as the concentrator was set below the ordered amount. Additionally, the resident's nebulizer mask was left unbagged and not changed per facility policy, exposing it to the environment. The DON and Regional Nurse Consultant confirmed these deficiencies.
Three residents did not receive multiple doses of their physician-ordered medications due to pharmacy order rejections, billing issues, and communication problems between facility staff and the pharmacy. Missed doses were documented in the MAR, and staff interviews confirmed delays and difficulties in obtaining medications, with some instances lacking proper documentation for the missed administrations.
Three medication errors occurred out of 30 opportunities when two residents did not receive scheduled doses of amlodipine, atorvastatin, and Tiadylt ER because the medications were unavailable at the time of administration. The CMT notified the LPN about the missing medications, and the DON later stated that staff should use the emergency supply if medications are not on the cart. This resulted in a medication error rate of 10 percent.
Expired Syringes Not Discarded per Policy
Penalty
Summary
The facility failed to properly discard expired syringes stored in the medication storage room, as observed during a survey. A sealed zip lock bag containing syringes with an expired date was found, and the Registered Nurse Supervisor (RNS) confirmed the syringes were expired. The facility's policy requires contacting the dispensing pharmacy for instructions regarding the return or destruction of outdated or deteriorated medications or biologicals, but this procedure was not followed in this instance. The RNS admitted she had not contacted the pharmacy about the expired syringes. Further interviews revealed inconsistencies in staff accounts regarding the handling of the expired syringes. The Director of Nursing (DON) took possession of the bag, partially opened it, and removed the label, later contacting the pharmacy for clarification using the lot number. However, the pharmacy's Director of Clinical Services stated that only a lot number was provided and that she was still awaiting a response from the manufacturer regarding the expiration status. The failure to promptly and properly address the expired syringes was confirmed through staff interviews and direct observation.
Failure to Date Thawed Health Shakes in Nourishment Rooms
Penalty
Summary
The facility failed to ensure that health shakes stored in nourishment room refrigerators on both the first and second floors were properly dated to indicate when they were removed from the freezer and placed under refrigeration. During inspections with the Dietary Manager, it was observed that multiple cartons of shakes in both nourishment rooms lacked documentation of the date they were thawed, despite manufacturer instructions and facility policy requiring such labeling. The Dietary Manager and Registered Dietitian both confirmed that the shakes must be used within 14 days of refrigeration, and that proper dating is necessary to ensure compliance with this requirement. This deficiency was identified through observation, interview, and review of facility policy, and had the potential to affect the majority of residents receiving an oral diet.
Failure to Follow Enhanced Barrier Precautions During Enteral Feeding
Penalty
Summary
A deficiency was identified when a nurse failed to follow the facility's infection prevention and control policies regarding Enhanced Barrier Precautions (EBP) during the care of a resident with an enteral feeding tube. The facility's policies require the use of both gown and gloves during high-contact activities such as enteral feeding or medication administration via a feeding tube. During an observed medication and feeding administration, the nurse donned gloves but did not wear a gown as required by the EBP protocol. The resident involved had significant medical conditions, including paraplegia, aphasia, a history of traumatic brain injury, and required enteral feeding through a gastrostomy tube. The resident's care plan and physician orders indicated the need for EBP. The nurse later confirmed that she did not wear a gown during the procedure and attributed this to the absence of a PPE cart at the resident's door and forgetting the requirement. The Director of Nursing confirmed that the expectation was for staff to use both gown and gloves for any procedures involving the enteral feeding tube.
Failure to Maintain Privacy for Residents with Indwelling Urinary Catheters
Penalty
Summary
Staff failed to maintain privacy for two residents with indwelling urinary catheters, as required by facility policy. For one resident with diagnoses including urinary tract infection and depression, observations showed the urinary catheter drainage bag was attached to the wheelchair without a privacy cover, leaving the urine visible to others. On a separate occasion, the same resident had a privacy bag covering only the drainage tubing, not the drainage bag itself. The resident required assistance for all activities of daily living and had little to no cognitive impairment. Another resident, with diagnoses including urinary tract infection and urethral stricture, was observed lying in bed with a urinary catheter drainage bag secured to the bed railing without a privacy cover. This resident also had little to no cognitive impairment and an indwelling urinary catheter. Staff interviews confirmed that all residents with urinary catheter drainage bags should have privacy covers, and that the facility policy requires privacy bags to be used at all times when catheters are in use.
Failure to Maintain Clean and Sanitary Resident Bathrooms
Penalty
Summary
Staff failed to maintain resident bathrooms in a clean and sanitary condition in three of seven observed restrooms. Observations revealed the presence of brown substances on handrails, toilet seats, and over-toilet seat handles, as well as soiled pads and washcloths with fecal odor left in the bathrooms. Strong odors of urine and feces were noted in all three bathrooms, and photographic evidence was obtained to document these findings. The facility's policy on routine bathroom cleaning requires removal of soiled linen, cleaning of wall attachments, support railings, and thorough disinfection of toilets, but these procedures were not followed as evidenced by the observed conditions. Interviews with housekeeping staff and the environmental supervisor indicated that housekeeping was responsible for general cleaning and disinfection, while CNAs were tasked with cleaning up bodily fluids. However, the division of responsibilities led to confusion and incomplete cleaning, resulting in unsanitary conditions. The administrator confirmed the expectation for clean resident rooms and bathrooms, with nursing staff responsible for bodily fluid cleanup and housekeeping for disinfection, but the observed deficiencies showed this process was not effectively implemented.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written bed hold information to a resident and/or their representative at the time of transfer to a hospital, as required by both facility policy and regulatory standards. The policy specifies that written information regarding bed hold practices must be given both at admission and at the time of transfer for hospitalization or therapeutic leave. In the case reviewed, a resident was transferred to a short-term general hospital with return anticipated, but there was no documentation in either the electronic medical record or paper chart that the bed hold notice was provided at the time of transfer. Interviews with staff confirmed that the bed hold policy notice was not completed or given to the resident or their representative at the time of the hospital transfer. The LPN stated that nurses were responsible for this task but acknowledged it was not done for this resident. The DON also confirmed the omission, noting that the bed hold policy was not completed for the resident at the time of transfer. This lapse was consistent with the facility's practice prior to a recent change in procedure.
Failure to Transcribe Physician Order for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when staff failed to transcribe a physician's verbal order for an indwelling urinary catheter into the electronic medical record for one resident. The facility's policy requires that indwelling urinary catheters be used only when clinically necessary and that all such use be in accordance with physician orders, including documentation of the diagnosis, catheter size, and frequency of change. Despite this, review of the resident's order summary report showed no order for the catheter, even though a progress note documented a verbal order and the catheter was placed. Observations on two separate days confirmed the resident had an indwelling urinary catheter in place. The resident, who was admitted with diagnoses including urinary tract infection and congestive heart failure, reported the catheter was used to monitor urinary output due to fluid retention and heart failure. During interviews, an LPN confirmed that although a verbal order was received, it was not transcribed into the physician's orders, and the DON stated that staff are expected to document and transcribe such orders directly into the electronic health record.
Failure to Administer Oxygen Therapy per Physician Order and Maintain Sanitary Respiratory Equipment
Penalty
Summary
Staff failed to administer oxygen therapy according to the physician's order and did not maintain respiratory equipment in a sanitary manner for one resident. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified chronic bronchitis, and hypoxemia with dependence on supplemental oxygen, had a physician's order for oxygen at two liters per minute (LPM) via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set between one and one and a half LPM, which did not match the physician's order. Additionally, a nebulizer mask used by the resident was found hanging unbagged and exposed to the environment, with a date indicating it had not been changed in accordance with facility policy. The facility's policy required that nebulizer tubing and delivery devices be changed every 72 hours or as needed if soiled, and that delivery devices be kept covered in a plastic bag when not in use. Interviews with the DON and Regional Nurse Consultant confirmed these findings.
Failure to Obtain and Administer Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician-ordered medications were obtained from the pharmacy and administered at the designated times for three residents. For one resident with diagnoses including hypertension and hyperlipidemia, there were multiple documented instances where prescribed medications such as amlodipine besylate and atorvastatin calcium were not administered as ordered. The medication administration record (MAR) indicated missed doses, with pharmacy alerts showing that orders would not be filled due to rejection, requiring resubmission at a later date. Staff interviews confirmed that the medications were not available and that communication regarding missing medications was relayed to nursing staff. Another resident with chronic diastolic heart failure, Parkinsonism, and other conditions did not receive several doses of critical medications, including Sinemet, amiodarone hydrochloride, and apixaban, as ordered by the physician. The MAR showed missed doses without documented reasons or with codes indicating the need to see nurse notes. Pharmacy alerts indicated that some medication orders were rejected and not filled. Interviews with the DON and Corporate Nurse Consultant revealed that the process for reordering medications involved using the MAR, and if medications were unavailable, staff were expected to use emergency supplies or contact the pharmacy. A third resident with hypertension did not receive several doses of Tiadylt ER as ordered. The MAR reflected missed doses, some without documentation and others marked with a code for further explanation. Pharmacy staff indicated that a new order was required and that a billing issue delayed delivery. Additional interviews with facility staff and pharmacy personnel highlighted ongoing problems with the pharmacy reordering process and communication issues, resulting in delays in medication delivery and administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three medication errors out of 30 opportunities observed for two residents. For one resident, physician orders indicated daily administration of amlodipine besylate and atorvastatin calcium, both scheduled for the morning. On the day of observation, these medications were unavailable for administration, and the Certified Medication Technician (CMT) reported the issue to the Licensed Practical Nurse (LPN), who was to locate or order the medications from the pharmacy. The CMT confirmed that the amlodipine had been ordered previously. For another resident, physician orders required daily administration of Tiadylt ER 24-hour oral 180 mg capsule, also scheduled for the morning. During observation, this medication was not available for administration and was not present in the emergency medication stock. The CMT confirmed the unavailability, and later, the Director of Nursing (DON) and Corporate Nurse stated that staff should obtain medications from the emergency supply if not available on the cart. These events resulted in a medication error rate of 10 percent, exceeding the acceptable threshold.
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