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
111632 A. BUILDING __________
B. WING ______________ 		09/15/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HALCYON HOSPICE 515 NORTH SAINT AUGUSTINE ROAD, SUITE D, VALDOSTA, GA, 31601
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)
L0505      
38966 Based on clinical record review, staff, and family interviews the hospice agency failed to respect Resident (R#1) Patient Rights. Resident #1 told Certified Nursing Assistant (CNA AA) that she did not want a shower or bath because she was not feeling good. CNA AA coax her to get up and upon getting R#1 up for a shower R#1 sustained skin tears on both arms. Finding include: Review of the initial assessment revealed R#1 was admitted to hospice services on August 25, 2020, with diagnoses, including Alzheimer's with agitation. On September 14, 2020 at 12:10 p.m., an interview was conducted with CNA AA who stated that on August 31, 2020 she visited R#1 who lives in an Assisted Living Facility (ALF) to assist her with activity of daily living. CNA AA stated that the ALF staff told her that R#1 did not have a shower or bath for the past few days and she wanted CNA AA to coax R#1 to bathe. CNA AA said R#1 told her that she did not want a shower or bath because she was not feeling good. CNA AA stated that she was trying to help R#1 to get up and put her on the commode and R#1 fought back and sustained skin tears on both arms. CNA AA pressed the call light and CNA BB came in and asked what happened? R#1 said, " I fought her." CNA AA stated, "Thank God she told the truth". During an interview with the Hospice Administrator/Director of Nursing on September 14, 2020 at 12:20 p.m., she stated , (R#1) has been through an excessive amount of trauma in the past couple of years, she lost her home in hurricane, multiple strokes, son, and husband passed away this year. I was there to help and support her. She further stated to the surveyor, "I explained what happened in the incident report you can read it. Review of R#1's clinical record and incident report dated September 1, 2020 in part revealed that the Hospice DON investigated the incident that occurred on August 31,2020 and notified P#1's physician and family. On September 14, 2020 at 12:25 p.m., an interview was conducted with Registered Nurse (RN CC), who previously worked with R#1 at a different hospice agency. RN CC stated, "R#1 had a history of delusions sometimes related to the trauma of losing her house in a hurricane, loss of her husband and son. "RN CC also stated that R#1 was never combative with staff to his knowledge." On September 14, 2020 at 12:50 p.m., a phone interview was conducted with the Assisted living ALF Administrator who stated that R#1 told her that CNA AA came to her room and talked to her about taking a bath and the R#1 told CNA AA that she did not want to take a bath because she was not feeling well. R#1 stated CNA AA "swung "her legs off the bed, pulled her up by her arms and started undressing her. R#1 told ALF Administrator that she was combative with CNA AA. The ALF Administrator reported the incident to ALF Divisional Director of Operations and Adult Protective Services. The ALF Administrator stated that she has known CNA AA, for years and has never had a complaint. ALF Administrator stated that she referred R#1 to Hospice because of the good care that CNA AA always gave to her residents. On September 14, 2020 at 12:55 p.m., the surveyor requested to talk to R#1, the ALF Administrator went to R#1 ' s room and gave R#1 the phone. The surveyor greeted and asked R#1, do you remember what happened between you and CNA AA, on August 31, 2020 related to a bath? R#1 replied "Yes, I remember CNA AA, came to my room, she said that she wanted to assist me with a bath. I told her I am not feeling good and I didn't want a bath nor shower. The next thing I remembered was she grabbed both of my arms and started to undress me. I fought back and she hurt me, I am afraid of her. " On September 14, 2020 at 2:07 p.m., an interview was conducted with R#1's family member who stated that her mother didn't want to talk to her about the incident. R#1' s family member confirmed that she received a phone call from the ALF Administrator and the hospice DON related to the incident and she was not happy. R#1' s family member stated that her mother was never combative with staff before. During the interview R#1' s daughter verbalized that she was happy that the state was investigating the incident. On September 14, 2020 at 2:15 p.m., an interview was conducted with the Hospice RN DD who stated that CNA AA, is one of the best staff they have. RN DD also mentioned that he has been working with CNA AA for 8 years and no patient or family ever complained or reported any negative behavior about CNA AA. RN DD said he would recommend CNA AA to take care of his family. On September 15, 2020 at 10:21 a.m., during interview with CNA BB who works at the ALF she stated that on August 31, 2020 she answered the call light from R#1's room. " I saw the resident fighting the hospice CNA AA and I try to stop her, and we discovered that the R#1 had skin tears on her arms. I talked to R#1 to stop the fight and she did. I reported the incident to the nurse."