Survey Report for 111572

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	111572	A. BUILDING __________ B. WING ______________	08/28/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
PRUITTHEALTH HOSPICE-SWAINSBORO	667 S MAIN STREET, SWAINSBORO, GA, 30401
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)
L0776
L0776	42460 Based on record reviews and staff interviews the hospice failed to ensure changes to the hospice plan of care were discussed with the patient representative and nursing home representative for one of three patient records reviewed. Finding include: Review of patient # 1 medical record (dates 7/21/20-8/3/20) revealed the patient was declining and beginning to develop skin problems. At the care plan review meeting on 7/22/20 the Interdisciplinary group (IDG) discussed the patient's condition and care plan. It was determined to add a low air loss mattress to the patient's bed. This change was signed by the IDG and the Medical Director on 7/22/20. However, there was no documentation on patient #1's medical record showing any collaboration or discussion between the hospice, the nursing home, or the family related to the implementation of the mattress. On 7/31/20 the Registered Nurse (RN) documented the low air loss mattress was in place. There was no other documentation referring to the mattress. In a phone interview with the patient's primary RN on 8/27/20 at 11:33 a.m., the RN stated she had not discussed adding the mattress to the patient's plan of care with the family. In an email dated 8/27/20 at 4:51 p.m. from the Assistant Director of Health Services (ADHS), the ADHS confirmed there was no other documentation on the medical records referring to the implementation of the low air loss mattress.