Tennessee Veterans Home

In the surveyor’s words

From the most serious findings on record at Tennessee Veterans Home, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835May 15, 2024

  Based on the Board of Examiners of Nursing Home Administrators (BENHA) review, job description review, policy review, and interview, Administration failed to provide oversight of staff to ensure an adequate and thorough investigation was conducted to determine a root cause for Residents #9 and Resident #10's major injuries of unknown origin. Administration also failed to provide oversight and supervision of staff to prevent resident neglect when they failed to ensure physician's orders for wound care were followed for Residents #7, #9, #12, #13, and #14. Administration failed to provide oversight and supervision to ensure nursing staff provided effective pain management when Resident #10 sustained a major injury and experienced unresolved severe pain. […]

• Immediate jeopardy, widespreadF867May 15, 2024

  Based on facility policy review, job description, Quality Assurance Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, and interview, the QAPI committee failed to ensure an effective QAPI program that identified quality deficiencies and implement performance improvement activities to address quality concerns related to resident neglect, thorough investigations for adverse events which included major injuries of unknown origin and providing effective pain management. The QAPI committee failed to provide oversight that established and implemented policies and procedures to assure the facility was administered in a manner to use its resources effectively and efficiently. The census on entrance was 114. […]

• Immediate jeopardy, patternF600May 15, 2024

  Based on facility policy review, Quality Assurance Performance Improvement Plan review, QAPI Meeting Minutes review, medical record review, observation, and interview, the facility failed to ensure all residents were free from neglect for 5 of 12 residents (Resident #7, Resident #9, Resident #12, Resident #13, and Resident #14) who required wound care. The facility's failure to provide goods and services for residents resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) when Resident #7 did not receive wound care as ordered by the physician for a wound identified on 12/17/2023 as excoriation (skin is scraped or… […]

• Immediate jeopardy, isolatedF610May 15, 2024

  Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation and take appropriate corrective actions for 2 of 2 (Residents #9 and #10) sampled residents reviewed for injuries of unknown origin. The facility's failure to conduct a thorough investigation related to Resident #9's right displaced tibia (shin bone) fracture identified on 10/3/2023, and Resident #10's subtrochanteric right femur fracture (proximal femur fracture located within 5 centimeters of the lesser trochanter of the right femur) identified on 11/5/2023, resulted in an Immediate Jeopardy related to Resident #9 and #10. […]

• Immediate jeopardy, isolatedF697May 15, 2024

  Based on facility policy review, medical record review, and interview, the facility failed to implement an effective pain management regimen for 1 of 6 (Resident #10) sampled residents reviewed for pain management. Resident #10, who was cognitively impaired and vulnerable, remained in the facility and experienced moderate to severe pain without effective pain management for approximately 15 hours before being transferred to the hospital. Resident #10 sustained a subtrochanteric right femur fracture (proximal femur fractures located within 5 centimeters of the lesser trochanter of the right femur). […]