DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
111504 A. BUILDING __________
B. WING ______________ 		11/23/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE SAVANNAH 1352 EISENHOWER DRIVE, SAVANNAH, GA, 31406
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0508      
44327 Based on clinical record reviews, interviews with agency staff, review of the agency's complaint log, personnel record reviews and review of agency policy titled " Reporting Abuse and Neglect or Exploitation" revisited 9/21, it was determined the agency failed to report allegations of physical and verbal abuse to the State agency in a timely manner. Review of personnel records revealed two reports alleging physical and verbal abuse of three inpatient unit (IPU) patients by an Certified Nursing Assistant (CNA #AA) in three of three patient (P) (P#1, P#2 and P#3) records reviewed. 1. Patient #1 was admitted on 2/18/21,with the hospice diagnosis of senile degeneration of the brain . P#1's clinical record was reviewed for certification period 10/16/21 to 12/14/21. P#1 was at the agency's inpatient unit (IPU) for respite care from 10/23/21 to 10/28/21. The reported documentation of alleged abuse by CNA #AA against P#1 occurred on 10/26/21, and was reported to the agency's IPU Clinical Manager Licensed Practical (LPN) #CC on 11/1/21, per an agency provided document attached to another agency document dated 11/4/21, titled "Employee Coaching/Counseling". Attached to the "Employee Coaching/Counseling" form was a handwritten statement provided by CNA #BB. The handwritten statement documents CNA #BB observed CNA #AA on 10/26/21, "grab the patient right arm and bend the patient arm back more than once. The patient yelled out while (CNA #AA) bend (sic) arm." CNA #BB's documentation also reports that CNA #AA "pinch the patient nose" and called P#1 a "bitch". Patient #1 did not receive a visit by a Registered Nurse (RN) to complete an assessment for possible physical or psychosocial injuries immediately after the agency having knowledge of the incident. A routine comprehensive health assessment was documented as completed on 11/4/21. The agency provided the surveyor with documentation of the agency's IPU Clinical Manager LPN #CC and the agency Director of Clinical Strategy and Compliance Registered Nurse (RN #DD) on 11/4/21, counseling and a human resources corrective action plan entitled "Employee Coaching/ Counseling" that was provided to CNA #AA on 11/4/21. However, the agency did not provide evidence of documentation to include reporting the alleged incident to P#1's family or physician. There was no documented evidence provided to the surveyor to confirm the agency conducted an investigation of the alleged incident. 2. Patient #2 was admitted on 6/28/21, with the hospice diagnosis of Alzheimer's disease . P#2's clinical record was reviewed for certification period 9/26/21 to 12/24/21. P#2 was at the agency's IPU for respite care from 10/27/21 to 11/1/21. The reported documentation of alleged abuse by CNA #AA against P#2 and was reported to the agency's IPU Clinical Manager LPN #CC on 11/1/21, per an agency provided document attached to another agency document dated 11/4/21, titled "Employee Coaching/Counseling". Attached to the "Employee Coaching/Counseling" form was a handwritten statement provided by CNA #BB. CNA #BB provided handwritten documentation in which CNA #BB documents observing CNA #AA on 10/30/21, "struck the patient on the head and patient began yelling loud." The report also documented P#2 "start swinging at us with her hands, so after that (CNA #AA) grab patient right arm and bend it back to were (sic) the patient said, 'YOU HURTING ME'." The report also documents, "Then the patient said something to were (sic) (CNA #AA) was about to get at (P#2) again so I (CNA # BB) jump in front of (CNA #AA) and said no please no just leave her. So, after that we (CNA #AA and CNA#BB) pulled the patient up in the bed and I got the heck out of the room and went to the nurse station and told the charge nurse." The IPU Charge Nurse at that time was RN #EE. During the survey the agency made available to the surveyor an email dated 11/3/21, at 12:16 p.m. The email was addressed to IPU Clinical Manager LPN #CC from IPU Charge Nurse RN #EE stating: "On 10/30/21, this nurse went to administer medication to (P#2) who was displaying agitation as evidenced by continual screaming. (CNA #BB) and (CNA #AA) were already in the room. As this nurse administered said medication, patient attempted to grab at said nurse. (CNA #AA) attempted to hold (P#2) arms back, bending one in the process. Patient proceeded to state 'Ouch, you're hurting me'. CNA #AA let the patient loose." Patient #2 did not receive a visit by a RN to complete an assessment for possible physical or psychosocial injuries immediately after the agency having knowledge of the incident. A routine comprehensive health assessment was documented as completed on 11/3/21. The agency provided the surveyor with documentation by the agency's IPU Clinical Manager LPN #CC and the agency Director of Clinical Strategy and Compliance RN #DD dated 11/4/21. The documentation contained counseling and a human resources corrective action plan entitled "Employee Coaching/ Counseling" that was provided to CNA #AA on 11/4/21. However, there was no documented evidence on the document of reporting the alleged incident to P#2's family or physician. No documentaton evidence was provided to the surveyor to confirm that an investigation was done regarding the alleged incident. 3. Patient #3 was admitted on 3/1/21, with the hospice diagnosis of Alzheimer's disease . P#3's clinical record was reviewed for certification period 4/30/21 to 6/28/21. The report regarding alleged physical abuse against P#3 was made by an anonymous agency staff member, who reported the incident to the hospice agency on 6/14/21. The alleges the incident took place on 6/4/21. The description of the occurrence in the agency report documented that CNA #AA was providing supervision to P#3. The agency report documents that CNA #AA was witnessed by the anonymous reporter sitting with P#3 and "popped patient on her hand and told her not to do that" when P#3 repeatedly reached for items at the nurse's station. The agency report documentation contains documentation of an interview with CNA #AA as well as counseling CNA #AA. The documentation of the counseling session with CNA #AA was not dated. Per the agency documentation of the event on the agency form entitled "Occurrence Report/Opportunity for Improvement" dated 6/14/21, the agency had no further documentation of investigation activities nor notification of P#3's physician or family. P#3 did not receive a visit by a RN to complete an assessment for possible physical or psychosocial injuries immediately after the agency having knowledge of the incident. A routine comprehensive health assessment was documented as completed on 6/15/21. The agency provided the surveyor with documentation of the agency's IPU Clinical Manager LPN #CC and the agency Director of Clinical Strategy and Compliance RN #DD of counseling and a human resources corrective action plan entitled "Employee Coaching/ Counseling" that was provided to CNA #AA on 11/4/21. However, there is no documentation on the agency document of reporting the alleged incident to P#2's family or physician. There is no documentation of further investigation of the alleged incident. CNA #AA was unavailable to interview at the time of the onsite investigation. CNA # AA voluntarily resigned from the agency on 11/18/21. CNA #BB was contacted via phone on 11/23/21 but did not answer. A voice mail was left requesting a call back to the surveyor The agency Administrator, Vice President of Clinical Services and the Director of Clinical Strategy and Clinical Compliance were informed of the above facts in an interview at the agency at 4:00 p.m. on 11/23/21.
L0591      
44327 Based on clinical record reviews and review of agency policy titled, "Reporting Abuse and Neglect or Exploitation, the agency failed to provide nursing care and services by a Registered Nurse (RN) or under the supervision of a (RN) for three of three patients (P) (P#1, P#2, P#3) records reviewed for abuse allegations. 1. Patient #1 was admitted on 2/18/21, with the hospice diagnosis of senile degeneration of the brain . P#1's clinical record was reviewed for certification period 10/16/21 to 12/14/21. P#1 was at the agency's inpatient unit (IPU) from 10/23/21 to 10/28/21, for respite care. The agency received a handwritten document from Certified Nursing Assistant (CNA #BB) reporting physical and verbal abuse towards P#1 by CNA #AA on 11/1/21, while P#1 received care at the IPU. The handwritten document alleges the abuse occurred on 10/26/21. Although the agency received the document on 11/1/21, from CNA #BB, the agency could not provide evidence than an updated comprehensive assessment was completed by an agency RN until 11/4/21. 2. Patient #2 was admitted on 6/28/21,with the hospice diagnosis of Alzheimer's disease . P#2's clinical record was reviewed for certification period 9/26/21 to 12/24/21. P#2 was at the agency's IPU from 10/27/21 to 11/1/21 for respite care. The agency received a handwritten document from CNA #BB reporting physical abuse towards P#2 by CNA #AA on 11/1/21, while P#2 was receiving care at the IPU. The handwritten document alleges the abuse occurred on 10/30/21. Although, the agency received the report on 11/1/21, from CNA #BB, the agency could not provide evidence that an updated comprehensive assessment was completed by an agency RN until 11/3/21. The agency's policy, entitled "Rights and Ethics 401", revised 9/21, requires that the patients's medical record will reflect the assessment, interventions and documentation of appropriate referrals. The policy also states that the abuse will be reported to the team manager and Vice President of Clinical Services immediately. CNA #BB failed to provide the report immediately per the agency's policy. 3. P#3 was admitted on 3/1/21, with the hospice diagnosis of Alzheimer's disease . P#3's clinical record was reviewed for certification period 4/30/21 to 6/28/21. P#3 was at the agency's IPU from 6/3/21 to 6/7/21, for respite care. On 6/14/21, the agency received an anonymous written report of abuse towards P#3 on the agency form entitled "Occurrence Report/Opportunity for Improvement", revised 6/21. The report alleges the abuse occurred on 6/4/21. The report was submitted to the agency by RN #FF on the agency provided form but contained documentation that the actual reporter was anonymous. The agency failed to follow its written policy, entitled "Rights and Ethics 401", revised 9/21, #8 which includes the patients medical record will reflect the assessement, interventions and referral. And #9, if abuse by a Hospice Savannah employee is suspected, the team manager and Vice President of Clinical Services will be notified immediately. The employee will be reassigned from direct clinical care until and internal investigation can be completed. The agency received the report on 6/14/21, and P#3 received a nursing assessment on 6/1521. However, the nursing assessment did not contain any documentation of the alleged abuse. The agency Administrator, Vice President of Clinical Services and the Director of Clinical Strategy and Clinical Compliance were informed of the above facts in an interview at the agency at 4:00 p.m. on 11/23/21.
L0651      
44327 Based on review of the agency's polices titled "Rights and Ethics 401: Reporting Abuse and Neglect or Exploitation", revised 9/21, staff interview and clinical record review, the Administrator failed to provide oversite of the agency as designated by the Governing Body. Failure of the administrative oversite was revealed upon review of three of three patients (P) (P#1, P#2 and P#3) records reviewed for abuse allegations. 1. The agency received an allegation of abuse on 11/1/21, towards P#1 by Certified Nursing Assistant (CNA) #AA. P#1 was residing at the agency's inpatient unit (IPU) receiving respite care at the time of the alleged abuse. The alleged abuse was reported to have occurred on 10/26/21. 2. The hospice agency received an allegation of abuse on 11/1/21, towards P#2 by CNA #AA. P#2 was residing at the agency's IPU receiving respite care at the time of the alleged abuse. The alleged abuse was reported to have occurred on 10/30/21. 3. The agency received an allegation of abuse on 6/14/21, towards P#3 by CNA #AA. P#3 was residing at the agency's IPU recviing respite care at the time of the alleged abuse. The alleged abuse was reported to have occurred on 6/4/21. The administrator failed to provide oversite to the agency and follow the agency policy titled "Rights and Ethics 401", revised 9/21, by not taking the following actions immediately upon receipt of the report of the alleged abuse: The administrator failed to provide oversite to the agency and follow the agency policy titled "Rights and Ethics 401", revised 9/21, by not taking the following actions immediately upon receipt of the report of alleged abuse: a. #6 of the policy requires a verbal report of any allegations of abuse to be made to Adult Protective Services Central Intake Division of the Georgia Department of Human Resources. The Administrator failed to provide oversite by not reporting the allegation of abuse to this entity. b. #7 the policy requires the agency to report any allegations of abuse to be reported to Georgia Department of Community Health within 24 hours or the next business day. The Administrator failed to ensure the department was notified of the allegations of abuse. c. #8 the policy requires the agency to document assessment, interventions and referrals in the medical record for any patient for whom there are allegations of abuse. The Administrator failed to provide oversite by not ensuring that documentation in the medical record of P#1 to reflect comprehensive physical and psychosocial assessment, interventions and referrals for the possible abuse. d. #9 the policy requires the agency to reassign any employee suspected of abuse to nonclinical duties. The Administrator failed to provide oversite by failing to remove CNA #AA from clinical care of patients on after being notified of the possible abuse 11/1/21. CNA #AA provided direct patient care on at the agency's IPU on 11/2/21, 11/3/21 and 11/4/21. The Administrator was made informed via email provided by the Department of Community Health, Division of Healthcare Regulation on 11/23/21 at 4:05 p.m.