SAVANNAH, GA- THUNDERBOLT CARE CENTER

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.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on observations, interviews, and record reviews the facility failed to follow dietary orders for one resident (R) (R572) of 53 sampled residents. Specifically, R572 was on a puree diet but was provided a sandwich on 11/12/2024 which resulted in her choking death.

It was determined that the provider’s non-compliance with one of more requirements of participation had caused, or was likely to cause serious injury, harm, or death to residents.

Review of the Electronic Medical Record (EMR) for R572 revealed an initial admission date of 8/18/2020 with diagnosis that included CVA, dysphagia, oropharyngeal phase, cognitive communication deficit, and unspecified dementia. The diet order revealed a regular diet, pureed texture, with thin consistency starting 6/4/2024.

Review of the Regional Dietician (RD) Quarterly Assessment dietary note dated 10/17/2024 revealed that R572 is tolerating a puree diet with variable meal intake and is mostly fed by staff.

Review of Progress Notes dated 11/12/2024 at 7:50 am revealed that R572 was sitting at the dining table, Certified Nursing Assistant (CNA) sat at the table with resident stated, she’s not acting like herself, writer walked around the table to assess resident, noted a deli sandwich wrap and a cup of coffee sitting in front of her upon closer observation noted that she was cyanotic around her mouth, lips, tongue and oral membranes knowing that resident is on a puree diet ,CNA performed mouth sweep times 2 unsuccessfully, writer performed abdominal thrusts several times unsuccessfully, summoned for help, they arrived with crash cart,911 called, resident expired, DON notified and later pronounce death.

Review of GEORGIA DEATH CERTIFICATE for R572 lists the cause of death as cardiopulmonary arrest.

During an interview on 12/3/2024 at 1:40 pm with the DON regarding the death of R572. DON reported that she was aware of the R572’s death, but she has not followed up or spoken with the night CNAs that were potentially involved. The DON reported that she had left them messages, but neither has called her back because they are as-needed (PRN) employees. DON reported that since the incident a document is posted to indicate residents’ diet preferences in the Memory Care Unit. She reported that all staff on the Memory Care Unit have been educated but she also reported that she does not have any documentation to verify that education was provided as the nurse on the unit would have provided the education. DON acknowledged that she did not have any investigative information related to the death of R572. DON reported that no other resident had choked before.

During an interview on 12/5/2024 at 10:18 am with the Administrator he reported that when there is an unexpected death in the facility of a resident, the situation should be triaged, communicated to nursing leadership, and discussed in the morning meeting. The Administrator reported that he had not been fully informed of the situation with R572 at the time that it happened. The Administrator acknowledged that the DON pronounced R572, and he was not aware of a wrapper being in front of the resident at the time. He reported that he thought that LPN EEE educated the CNAs, but that was not enough. The Administrator reported that once the DON was aware of the circumstances of the death of R572, he should have been made aware, and there should have been in-servicing of the staff. It is reported that the Administrator found out about the circumstances of R572’s death on Tuesday night (12/3/2024).

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Review of the policy titled Accidents and Supervision, dated 4/1/2024, section; Policy revealed the resident environment will remain as free of accidents and hazards as it is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and risks, evaluating and analyzing hazard and risk, implementing interventions to reduce hazard and risk, and monitoring for effectiveness and modifying interventions. Item one a states all staff are to be involved in identifying potential hazards in the environment, while still taking into consideration the unique characteristics and abilities of each resident. Ite two b stated both the facility-centered and resident- directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing
potential causes for each accident hazard risk, and identifying or developing interventions based on severity and hazards and immediate risk.

Observation and interview on 12/01/2024 at 1:37 pm with R73 revealed in September 2023, he was elevated with the use of a mechanical lift, and the mechanical lift was malfunctioning. R73 stated he told the CNA that it wasn’t moving right, the wheels on front locked up, and it wasn’t rolling. R73 further stated the CNA turned the lift and rolled him backward while elevated, and the lift flipped over, resulting in him falling backward. R73 stated he hit the footboard and fell on a walker. R73 further revealed he was seen in the emergency department and admitted for three days. R73 further stated when he returned the mechanical lift was still being used.

Observation on 12/11/2024 at 7:45 am with MD PPP walked hallways to look at the mechanical lifts, finding one on the east hall. MD PPP stated it works properly based on control allowing the lift mechanism to move up and down. Observed in the [NAME] Hall to check two mechanical lifts, one mechanical lift of which had no controller at all, and the second checked in the same manner as the first.

During an interview on 12/12/2024 at 1:33 pm with Administrator revealed the mechanical lift was not in proper working order. He stated the Regional Maintenance person came and said that this did not happen in a day it had to have been out of proper working order for some time and should have been reported. The Administrator stated there was a bend in the bar; photos were provided of the mechanical lift. The Administrator further revealed that the check of seeing if the controller moves to lift in an up and down motion is substandard for a safety check.

Based on observations, residents and staff interviews, record review, and review of the facility policies titled Accident and Supervision, Oxygen Safety, and Resident Rights-Smoking, the facility failed to ensure a safe and secure environment free for residents and staff for three of 53 sampled residents (R) (R9, R73, R96).

Specifically, failed to ensure failed to ensure one resident (R ) (R9) had secured oxygen cylinders, one resident (R73) was provided with safety equipment during transfer, failed to ensure one resident (R96) was assessed for safe smoking. This failure had the potential to create risks for the safety and well-being of the residents, staff, and visitors in the building.

Observation of room [ROOM NUMBER] on 12/4/2024 at 1:04 pm revealed R9 sitting in the room in her wheelchair. Continued observation revealed two small oxygen cylinder tanks lying on the floor next to an oxygen holder containing six oxygen cylinders.

During an interview on 12/2/2024 at 2:10 pm at the time of observation of R9’s room with the Administrator, Register Nurse (RN) GGGG, and Certified Nursing Assistant (CNA) PPPP, all staff confirmed the two oxygen cylinders lying on the floor instead of the oxygen holders. RN GGGG confirmed that the risk could result in a hazardous fire. The Administrator acknowledged being unaware that oxygen was stored in the resident’s room. He reported that the oxygen tank holders and oxygen cylinder tanks would be relocated to another area.

Observation of the Memory Care Unit patio area on 12/1/2024 at 1:45 pm revealed R96 sitting outside on the patio in a chair with a smoking apron, smoking a cigarette under the observation of Licensed Practical Nurse (LPN) JJJ. LPN JJJ acknowledged that the resident was a smoker and smokes at least twice a day or more.

Record review of the admission MDS for R96 dated 9/9/2024 assessed a BIMS score of 13, which indicates cognitive awareness.

R96’s admission Package completed on 8/26/2024 included the resident facility smoking assessment (Section M: Smoking History) and smoking consent. Section M, Smoking History, assessed R96 as not a smoker. The consent form listed R96’s signature and documented that R96 was not a smoker.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on  observations, staff interviews, record reviews, and the facility policy titled Catheter Care, the facility failed to ensure that one of four residents’ (R) (R36) catheter tubing was not coiled and correctly positioned to prevent obstruction of urinary flow. In addition, the facility failed to ensure R36’s drainage bag was covered and secure (not dragging the floor) underneath the resident’s wheelchair. This deficient practice had the potential to put residents at risk for complications related to urinary health and with the possibility of urinary tract infections.

Observation on 12/1/2024 from 2:30 pm until 4:00 pm revealed R36 sitting in a room (door open) in a wheelchair with an attached catheter drainage bag. A continued review revealed that the catheter drainage bag was uncovered, the catheter tubing/catheter drainage bag was touching the floor, and the tubing was in a loop position around the resident’s foot. Continued review revealed both devices dragging on the floor as the resident propelled himself in the wheelchair in the room.

During an interview at the time of observation on 12/1/2024 at 3:30 of R36’s catheter, Licensed Practical Nurse (LPN), LPN JJJJ confirmed that the catheter drainage bag was not covered with a dignity bag, tube and catheter drainage bag was touching the floor underneath the wheelchair. She acknowledged that the tubing was coiled around the resident foot and obstructed the urine flow. She confirmed that the tubing was coiled and that the tubing and drainage bag touching the floor were infection control issues. She further reported that this could place the resident at risk of infection. She instructed a certified nursing assistant (CNA) MMMM to help her reposition the resident to prevent the catheter drainage bag and tubing from touching the floor. LPN JJJJ provided a dignity bag for the catheter.