Survey Report for 111673

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	111673	A. BUILDING __________ B. WING ______________	09/15/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ASSURED HOSPICE CARE LLC	9B MEDICAL DRIVE, NE, CARTERSVILLE, GA, 30121
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)
L0511
L0511	38966 Based on review of clinical records, and staff interview, it was revealed that the hospice agency failed to report incident to Healthcare Facility Regulation Division (HFRD) in a timely manner for of one (1) of one (1) hospice patient (P#1). The findings include: On 9/14/21, at 2:23 p.m., an interview was conducted with Certified Nursing Assistant (CNA) who stated that she visited P#1 on 8/23/21. Personal care home (PCH) staff told hospice CNA that on 8/22/21, at approximately 8:30 p.m., that a male patient with a diagnosis of dementia dragged P#1 who was also a dementia patient. The male patient dragged P#1 from bed to the floor and P#1 sustained bruise on right elbow and small skin tear on right upper shoulder covered with bandage. CNA notified the hospice office immediately. On 9/15/21, at 12:57 p.m., an interview was conducted with a Registered Nurse (RN) AA, who stated that on-call hospice agency staff received a phone call on 8/22/21, around 10:30 p.m., from P#1's PCH staff, stated that P#1's was dragged from bed to the floor by another patient. The PCH staff told the on-call nurse not to come because P#1 was okay. Hospice agency sent RN AA, on 8/23/21, to visit P#1. RN AA stated that during assessment it revealed that P#1 had bruise on right elbow and skin tear on the right upper shoulder. RN AA treated P#1 and notified patient's family and his Director of Nursing. On 9/15/21, at 1:00 p.m., an interview was conducted with Administrator, stated that they were notified by RN AA and CNA, and the Director of Nursing notified the corporate. The Administrator spoke with P#1's family and they moved P#1 on 8/26/21, to their inpatient hospice care for safety. Patient #1 expired on 9/12/21, not related to the incident per physician's report. The Administrator said that they did not notify Healthcare Facility Regulations Department (HFRD) because P#1's family called Adult Protective Services (APS).