Atrium Health Care Center

In the surveyor’s words

From the most serious findings on record at Atrium Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 5, 2023

  Based on interview and record review, the facility failed to monitor a cognitively impaired resident (R1), who was assessed to be at high risk for elopement and who had an electronic monitoring safety device on the right ankle; the facility staff failed to respond to alarms which may have sounded as R1 exited the building; and the facility failed to follow their elopement risk policy and procedures to prevent elopement. These failures affected R2, who speaks predominately Mandarin Chinese with limited understanding of English, who eloped from the facility on 9/12/23 without staff knowledge or supervision, has not returned to the facility and has not been located by the local police department which places R1 at a potential risk for harm when reviewed for improper nursing care in the sample… […]

• Actual harm, isolatedF600Jul 5, 2024

  Based on interviews and record reviews, the facility failed to keep two (R8, R10) of six residents free from abuse. This failure resulted in R8 and R10 sustaining a swollen and bruised eye. Findings include: 1. R10's clinical record document in part the following: R10 is a fifty-year-old with the medical diagnosis of schizophrenia, hypertensive heart disease with heart failure, acute ischemic heart disease, abnormalities of gait and mobility, and essential hypertension. R10's minimum data set brief interview of mental status dated 5/1/24 scored [8], indicates cognition is mildly impaired. […]

• Actual harm, isolatedF689Jul 5, 2024

  Based on observation, interview, and record review the facility failed to ensure safe practices when turning a resident in bed during resident care for 1 (R7) of three residents reviewed for falls. The facility also failed to ensure fall preventions were added to the care plan after R7's fall. This failure resulted in R7 falling out of bed and sustaining a laceration to the scalp. Findings Include: R7 has diagnosis not limited to Quadriplegia, Osteomyelitis, Hyperlipidemia, Muscle Spasm, Constipation, Postherpetic Polyneuropathy, Type 2 Diabetes Mellitus, Angina, Anxiety Disorder, Thiamine Deficiency, Vitamin D Deficiency, Bipolar Disorder, Schizophrenia, Chronic Pain, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock, Stage 4 and Essential (Primary) Hypertension. […]

• Actual harm, isolatedF689Jun 6, 2024

  Based on interview and records review, the facility failed to provide safe and adequate care for a resident (R1) of 3 residents reviewed for incontinence care and bed mobility, who requires two person-assist for incontinence care and bed mobility. This failure resulted in R1 falling out of bed, hitting his head on the bedside dresser, being transferred to the hospital on 2 different occasions post fall, and being diagnosed with post-concussion syndrome. Findings include: R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Quadriplegia, chronic embolism and thrombosis of deep veins lateral upper extremity, schizo-affective disorder, cocaine abuse, iron deficiency anemia, pain, unspecified, low back pain, essential (primary) hypertension,… […]

• Actual harm, isolatedF600May 2, 2024

  Based on interview and record review the facility failed to ensure the right of resident to be free of abuse for two (R4, R8) of six residents reviewed for abuse in the sample. This failure resulted in R4 being hit in the mouth sustaining facial trauma and R8 being hit in the nose resulting in bleeding and pain. Findings include: 1) R4 is a [AGE] year old male resident with a diagnosis including Schizophrenia, Deaf non speaking and Restlessness and agitation. R4 has a unscorable BIMS (Brief Interview for Mental Status). R4 is care planned for behavior symptoms concerning inappropriate personal boundaries due to diagnosis of Schizophrenia active 6/1/21. Symptoms are manifested by inappropriate touching. R4 will sneak up behind others and tap or grab them at the shoulders or back. […]