NHC Healthcare, Moulton

In the surveyor’s words

From the most serious findings on record at NHC Healthcare, Moulton, in the surveyor’s own words.

• Immediate jeopardy, widespreadF837Nov 4, 2022

  Based on interviews and review of the facility's Quality Assurance and Performance Improvement (QAPI) Manual, Subject: COMMITTEE MEMBERSHIP and Subject: GOVERNANCE AND LEADERSHIP, the governing body failed to provide oversight to the facility on the investigation and plans of action developed in QAPI, addressing Resident Identifier (RI) #1's accident on 9/26/2022 when RI #1's plans of care were not followed, and RI #1 was not provided assistance or supervision in accordance with his/her care plan. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. […]

• Immediate jeopardy, widespreadF867Nov 4, 2022

  Based on interviews, review of the facility's Quality Assurance and Performance Improvement (QAPI) Manual, Subject: GOVERNANCE AND LEADERSHIP and Subject: SAMPLE PLAN, and review of the facility's 10/20/2022 QUALITY IMPROVEMENT COMMITTEE MINUTES, the facility failed to ensure the QAPI committee thoroughly reviewed all causal factors related to Resident Identifier (RI) #1's fall from a wheelchair outdoors at the facility in order to develop an effective action plan to prevent any further resident safety concerns. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. […]

• Immediate jeopardy, isolatedF656Nov 4, 2022

  Based on record review, interviews, review of the facility's Fall Prevention Program, and review of the facility's Nursing Care Policies, the facility failed to ensure Resident Identifier (RI) #1's comprehensive care plans were implemented on 09/26/2022. RI #1's plan of care for falls had an approach that guided staff to assist with transfer and locomotion. RI #1 also had a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for communication problems and cognition deficits. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. […]

• Immediate jeopardy, isolatedF689Nov 4, 2022

  Based on observation, record review, interviews, review of the facility's investigative file related to a fall involving Resident Identifier (RI) #1, review of Patient Care Policies and review of the facility's policy titled SUBJECT: Incident and Accident Process, the facility failed to provide needed assistance and/or supervision to RI #1, a resident in a wheelchair, to prevent an accident outdoors at the facility on 09/26/2022. RI #1's plan of care for falls had an approach that guided staff to assist with transfer and locomotion. […]

• No harm, potential for more than minimal, patternF609Nov 4, 2022

  Based on record review, interviews, and review of a facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, the facility failed to ensure two allegations of resident-on-resident abuse were reported to the State Agency within two hours: 1) On 07/06/2022 Resident Identifier (RI) #4 was witnessed by staff slapping his/her roommate, RI #3, on the face and arm. The altercation was reported to the Director of Nursing (DON) and Abuse Coordinator/Administrator, but was not reported to the State Agency; and 2) On 07/24/2022 staff witnessed a resident-on-resident altercation between RI #4 and RI #5. […]