GAINESVILLE, GA- THE BELL MINOR HOME

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey, that can be found by clicking on “Full State Report” at the bottom.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on the interviews, record review, and a review of the facility’s policies titled Abuse Prevention Policy, Pressure Ulcer Treatment, and Prevention of Pressure Ulcers, the facility failed to ensure residents were free from abuse and neglect for three of six residents (R) (R159, R9, and R360) reviewed for abuse and neglect. (1) The facility neglected to emergently transfer R159 to the hospital per the family’s request and failed to notify R159’s physician after a change in condition, which resulted in a delay in treatment. (2) The facility failed to notify R9’s wound treatment provider of the worsening of the resident’s diabetic ulcer. (3) R360 was physically abused by her roommate (R46), who had a history of abusing other residents. These failures caused actual harm and death to the residents.

On [DATE], R159 was emergently transferred to the hospital, where she expired from complications related to the facility’s failure to notify the resident’s physician of her change in condition.

On [DATE], the facility failed to report the worsening of R9’s diabetic ulcer, and on [DATE], the resident sustained a below-the-knee amputation.

On [DATE], R360 was a victim of abuse when R46 had wrapped a call light cord around R360’s neck and then tied the call light cord to the bedrail.

On [DATE], a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.

The facility’s Administrator and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F580, F600, F658, F686, and F835 on [DATE] at 6:27 pm.

The facility was unable to provide an acceptable IJ Removal Plan before the survey team’s exit on [DATE], and the IJ remained ongoing

A review of R159’s Encounter Note dated [DATE] revealed the nurse reported R159 had a fluid-filled blister on the back of her left calf. R159’s family requested R159 be transferred to the ED (emergency department) for treatment, which was denied by Nurse Practitioner (NP) 3.

During an interview on [DATE] at 1:28 pm, F159 stated that on [DATE], she notified the nursing staff that R159 had a blister on the back of her calf. F159 indicated she asked the nursing staff and NP3 to send the R159 to the hospital because the nursing staff was not aware of the blister and was not receiving any treatment for the blister, but NP3 denied the request because she stated the resident could be taken care of at the facility.

On [DATE], R159 was emergently transferred to the hospital, where she expired from complications related to the facility’s failure to notify the resident’s physician of her change in condition.

A review of an undated statement written by LPN 11 revealed that she was notified on [DATE] that R9 had a wound on the right lateral side of his foot. It was approximately three to four inches in length. It had hard eschar, black in color and dry. It was pink around the outside of the area. I cleaned it with normal saline, patted it dry, and painted it with betadine per facility protocol, and it was left open to air. He had pedal pulses, it was not hot to the touch. Arrangements that the wound care provider (NP5) to see the resident the next day.

A review of a Skin/Wound Note dated [DATE] revealed R9 was seen for wound care management of a diabetic ulcer to his right lateral foot. Betadine was ordered for the treatment of the area. This was the first note written related to the wound being seen and assessed by a medical provider, three days after the wound was identified by nursing.

A review of an Evaluation and Management Report with date of service [DATE] revealed R9 was seen by a contracted wound Nurse Practitioner, NP5. NP5 documented the right foot wound as a diabetic ulcer, which measured 4 centimeters (cm) x 4.5cm x 0.2cm. The wound was 100% necrotic tissue.

In all three reports, the NP5 documented that R9’s heels were not floated, nor were the heel suspension boots used, and for the facility to: Monitor patient for any clinical signs and symptoms of infection or any further skin breakdown. Notify myself or the PCP [primary care provider] of any changes. Make sure the patient is being turned and repositioned frequently to help with wound healing and to help prevent any further skin breakdown. On [DATE], NP5 added that he Educated treatment staff to use heel boots to relieve pressure to the heels and will aid in wound healing. This can also relieve pain from constant pressure. On [DATE], NP5 also instructed the resident not to apply any pressure to the wound area as this may cause further skin breakdown.

A review of the Orders, Progress Notes, Care Plan, and Tasks tabs of the EMR revealed no order or
documentation that heel boots or turning and repositioning were implemented.

A review of a Nurse’s Note dated [DATE] at 6:13 pm revealed the physician had been notified that R9 refused most of his meals over the weekend, refused his blood sugar check that morning, as well as his scheduled medications and insulin. The note further documented that the resident spent a lot of his day in bed, covered with a sheet; that he covers his head with a sheet; noted a jerking movement, and had a strange affect; and altered mental issues. There was no mention of the wound on R9’s foot in this progress note.

A review of a Progress Note by NP4 with date of service [DATE] revealed NP4 was unable to palpate a pedal (top of foot), posterior tibial (behind ankle bone), or popliteal (behind the knee) pulse in the right lower extremity. The right lateral foot had a black eschar, had slightly malodorous drainage, and underneath the foot felt boggy. NP4 notified R9’s representative, Family Member (F)9, by phone that the foot was suspected to be gangrene. NP4 recommended immediate transfer to the ER (emergency room) for further evaluation.

A review of R9’s hospital records for [DATE] to [DATE] revealed R9 had an incision and drainage (I&D) completed on [DATE], which showed the wounds tracked to the bone in all areas with significant tissue loss of the right foot. On [DATE], a right below-the-knee amputation was completed. R9 was diagnosed with gangrene of the right foot and necrotizing cellulitis.

A review of R46’s comprehensive Care Plan dated [DATE] revealed a focus area for Risk for Harm: Self-directed or other directed with interventions of if resident poses a potential threat to injure self or others, notify provider and if safe allow resident personal space.

A review of R46’s Behavior Note dated [DATE] revealed Resident noted to be hiding roommates’ call bell from resident and not allowing roommate to have lights on per roommate request.

A review of R46’s Nurses Note dated [DATE] revealed that R46 continued to track down her roommate’s whereabouts and continued with her verbal abuse anytime staff were in the room to provide care for her roommate. She continued to put her roommate in a wheelchair every time her roommate wanted to go to the restroom and wheeled her to the toilet without requesting assistance from staff. She would come to the common area and demand that her roommate be taken back to her room, stating that she needs the resident in the room with her. She was upset that her roommate was taken for a shower or to eat in the dining room. It was documented that it is a toxic obsession that will cause harm to (the) roommate and will not allow (the) roommate to thrive in (a) social setting. At about 12:20 she came to common area and we thought she was ready for her shower, [sic] I went and to start wheeling her to shower and she swapped me with her hands and then at yelled for me to not hit her. I advised management to pull up cameras and ask all the CNAs and a resident that was right by her. The situation with this resident is completely out of control and is ramping up on a daily.

A review of R46’s Behavior Note dated [DATE] revealed Resident is exhibiting behaviors toward roommate that is making roommate tearful. Staff spoke with the resident to be mindful of the co-living situation and to respect the privacy of the roommate while staff are giving personal care. The resident has been observed pulling back the privacy curtain while staff is speaking with the roommate. Resident states, If she needs help, I just help her. Staff informed the resident that we are here to care for her and her roommate, but if her roommate needs help, she can help her by pushing her call light. Resident verbalized understanding.

A review of R46’s Nurses Note dated [DATE] revealed Resident noted to be standing over roommate. Resident noted to be verbally antagonizing roommate telling her ‘you can’t stay in here. You are going to have to go.’ Nurse asked resident if R46 was bothering her and resident states ‘yes she is. I’m just not feeling well and I don’t want to talk to anyone right now.’ Nurse advised R46 that her roommate did not wish to talk to her. R46 states this was my room first and you can’t tell me what to do. Resident continued to be verbally aggressive towards staff and roommate while she was receiving her medications. Resident behaviors are reported to the proper administration.

A review of R46’s Behavior Note dated [DATE] revealed R46 received a new roommate on [DATE]. The new roommate’s granddaughter states that her grandmother told her she was very uncomfortable in the room because R46 would not stop touching her and kept turning the volume off on her phone. The granddaughter states that when she came to see the resident, R46 would not let them in the room and then began slamming her drawers shut and turning the TV volume up. She states that she then saw her grab her grandmother’s phone and turn the volume off. Staff had a conversation with R46, and she denied touching her or her phone. The SSD informed the resident of their right to privacy and the co-living situation. She asked if the new roommate could move out and the rates for a private room. The Admissions Director was notified of interest in the private room.

A review of R46’s Nurses Note dated [DATE] revealed Resident returned from hospital via ambulance. No ss [signs and symptoms] of distress or discomfort noted. The resident was transferred to the hospital related to behaviors.

A review of R46’s Activities Note dated [DATE] revealed R46 was readmitted to the facility.

A review of R46’s Behavior Note dated [DATE] revealed that the social worker (SW) was called to the resident’s room due to a situation that was occurring. The resident was stating that the TV in her room was her personal TV. The note documented that the resident had taken the remote and hid it so the roommate could not watch television; the resident struck the SW and became angry during redirection. The SW then made a phone call to the resident’s family, who validated that the TV was not the resident’s and attempted to speak to the resident, but the resident was not listening. The resident’s behavior has escalated, and the SW documented that she would continue to monitor the resident and follow up with the medical director for further intervention.

A review of R46’s Nurses Note dated [DATE] revealed CNA7 reported that the call light cord was around her neck. I immediately went into the room, and the cord was lying across her chest. Upon inspection, the neck was normal in color. No redness, pain, bruising, swelling, or indentations of any kind were noted. The resident denied any pain. Resident continued with her normal ADLs [activities of daily living] throughout the day.

A review of R46’s Behavior Note dated [DATE] revealed SW informed by CNA7 of R360 that she removed the call light cord from around her, stating that R46 allegedly placed the cord around her. Profanity was exchanged between both residents. Follow up with MD [physician] to clinically intervene.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interviews, record review, and review of the facility’s policy titled Change in a Resident’s Condition or Status, the facility failed to ensure that two of 40 sampled residents (R) (R159 and R9), medical providers, and family were timely notified of a change in condition. R159’s medical provider was not notified of any changes in the resident’s condition, including the lack of pedal pulses.

Additionally, R159’s family was not made aware of the resident’s condition from 8/28/2024 until 9/7/2024. On 9/7/2024, R159’s family was concerned about the resident’s condition and requested that the resident be transferred to the hospital; however, the facility denied the request.

Additionally, on 5/15/2024, the facility identified a change in R9’s diabetic foot ulcer; however, the facility did not notify the resident’s wound practitioner, who was treating the wound, until 5/16/2024, when the resident was transferred to the hospital. In addition, the facility failed to notify R9’s family of a wound that had been treated since 4/15/2024. R9’s family did not become aware of the resident’s wound until 5/16/2024, when the resident was emergently transferred to the hospital.

These failures caused death to R159 and actual harm to R9

A review of R159’s Progress Note dated 8/28/2024 revealed, visit type: Acute . Pitting edema to BLE (bilateral lower extremities, bruising to the left foot. History of Present Illnesses .Staff concerned regarding worsening edema to BLE for the past 2-3 days, +2 to 3 pitting edema bilaterally. The patient spends most of the day in a wheelchair with feet down, and discussed with staff elevating the patient’s feet to help with edema reduction as well. Bruise to the left foot that was noticed yesterday. Unsure how the bruise was acquired. Patient does not elicit a painful response to the bruised area .Skin/Breast-Positive: Swelling, Bruises .Bruise to [NAME] surface of left foot .Edema .Pitting, Edema in lower left extremities, Edema in lower right extremities .

A review of the resident’s progress notes prior to 8/28/2024 revealed no documented evidence that the resident’s medical provider was notified of any edema or bruising to the resident’s foot.

A review of R159’s N Adv Skilled Evaluation dated 9/3/2024 revealed . Pain: Indicators of pain: None . Cardiovascular: Skin warm and pink with brisk capillary refill (< 3 seconds). No edema present . Calf tenderness is not present. Left pedal pulse: absent. Right pedal pulse: Absent . Skin: Skin warm & dry, skin color WNL, and turgor is normal . There was no documented evidence that the resident’s medical provider was notified that pedal pulses were absent.

A review of R159’s Encounter dated 9/10/2024, revealed . was seen and examined for a leg condition that apparently evolved over the course of 24 hours. Nursing had reported a rash over her lower extremities, and she was being treated with antibiotics for cellulitis. Discussed patient’s condition with her family on Monday, 9/9/2024. Family had some grievances regarding care . Ext RLE, LLE a few black areas on toes, and lateral/medial aspect of both feet, DP pulses unpalpable B/L . Imaging: Doppler result c/w arterial occlusion bilaterally . in view of patients chronic debility, h/o [history of] sepsis, gangrene on both extremities, and rapid decline, it was decided to send her to the ED immediately. Family was informed accordingly and expressed agreement.

During an interview on 3/26/2025 at 1:28 pm, Family Member (F) 159, when she visited R159 on 9/7/2024, she notified the nursing staff that R159 had a blister on the back of her calf. F159 also stated she requested that R159 be sent out to the hospital because nursing staff were not aware of the blister on the back of the resident’s calf, and so the resident could be treated for cellulitis because she knew it could lead to gangrene. F159 stated R159 was sent to the hospital on 9/10/2024 around 1:30 pm after she had an occlusion in her legs and was pronounced dead at 9:13 pm. F159 indicated the death certificate noted the cause of death was from acute hypoxic respiratory failure due to sepsis, acute renal failure, tubular necrosis, septic shock, and atherosclerosis of the native arteries of the extremities of gangrene.

During an interview on 3/27/2025 at 8:42 am, NP1 stated that when R159’s pedal pulses were absent on 08/31/24, the nurses should have informed the on-call provider and sent the R159 to the hospital since there was no in-house laboratory or imaging at the facility. NP1 stated she was not working at the facility at the time but confirmed that not notifying the provider timely could have led to the residents’ demise from not getting enough oxygen to the brain and circulation to the feet due to the occlusion in the lower extremities.

During an interview on 3/27/2025 at 11:01 am, NP2 confirmed nursing staff notified her on 09/07/24 that R159 had drainage to the top of the foot, so she ordered an antibiotic to prevent infection. NP2 also stated that had she been notified on 8/31/2024 that R159 did not have palpable pedal pulses, she would have requested a more thorough assessment of the resident. NP2 further stated she would have ordered the resident to be the hospital for more aggressive treatment of the resident’s condition to prevent the condition from worsening. The NP did not explain why she did not ask the nurse any other questions about the resident’s foot.

During an interview on 3/28/2025 at 10:37 am, the outgoing Medical Director stated it was his expectation that NP3 would have honored the family’s request to send R159 to the hospital. The continuing interview revealed as the facility’s Medical Director, he was responsible for the residents’ care in the facility; however, he needed the nursing staff to communicate changes in conditions to him.