Etowah Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Etowah Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 8, 2023

  Based on medical record review, review of facility policy, review of the facility self-reported intake report (FRI), investigation and witness statements, staffing data, review of video surveillance footage, National Weather Service (NWS) data, satellite imaging of the facility from Google Earth, observations and interviews, the facility failed to respond timely to delayed egress door alarms (doors equipped with magnetic lock/keypad system which can be opened with 15 seconds direct pressure to the door handle mechanism without use of the keypad system) on the main lobby door, which resulted in the elopement of 1 resident, (Resident #1, a cognitively impaired female, with limited mobility and endurance) of 6 residents reviewed for elopement risks. […]

• Immediate jeopardy, isolatedF689Jul 22, 2022

  Based on review of facility policy, medical record review, review of the facility self-reported incident (FRI), review of the video surveillance footage, review of National Weather Service (NWS) data, review of Satellite imaging (Google Earth), observations, and interviews, the facility failed to monitor and secure delayed egress doorways (doors equipped with a magnetic lock and keypad system which can be opened with 15 seconds direct pressure to the door handle without door codes) on the clinical units, which resulted in the elopement of 1 resident (#1) a cognitively impaired, ambulatory resident, with a history of wandering and other associated behaviors, of 9 residents reviewed. […]

• Immediate jeopardy, isolatedF725Jul 22, 2022

  Based on medical record review, observation, review of the facility layout, review of census, review of facility staffing, review of facility punch reports and payroll data, and interviews, the facility failed to maintain sufficient nurse staffing to monitor residents with behaviors. The facility's failure to ensure sufficient staffing resulted in the elopement of 1 resident (#1) of 9 residents reviewed. Resident #1 wandered to the delayed egress door on the D wing hallway and exited the building undetected around 3:40 PM on 7/4/2022, placing Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to resident). […]

• Immediate jeopardy, isolatedF726Jul 22, 2022

  Based on review of facility policies, medical record review, review of the Facility Self-Reported Incident (FRI), observations, interviews, and review of the Elopement Manuals (Happy Feet Manuals), the facility failed to maintain accurate and up to date elopement manuals at the nursing stations and failed to educate staff with facility policies and procedures for prevention of elopements and response procedures to be used for a missing resident. The facility's failure placed 1 resident (#1) of 9 residents reviewed, in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause serious injury, harm, impairment or death of resident) when Resident #1 wandered to the delayed egress door on the D wing… […]

• Immediate jeopardy, isolatedF835Jul 22, 2022

  Based on review of facility policies, record reviews, and interviews, the facility Administrator failed to maintain sufficient staffing levels on [DATE], failed to maintain staff competencies and compliance with the missing resident policy and procedures, and failed to take timely corrective actions to address the electronic anti-elopement system (Wanderguard) was not fully functional for 1 resident (Resident #1) of 9 residents reviewed. The facility's failures placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to resident). […]