SAVANNA HOUSE

INSP-0115542

Complete

Date: 4/2/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-04-07

Summary:

The following deficiency was found during the on-site investigation of complaint #00124831, conducted on April 2, 2025:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

R9-10-818.D.1. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 1. Immediately notifies the resident's emergency contact and primary care provider; and

Evidence/Findings:

Based on documentation review, record review, and interview, for one resident who had an accident, emergency, and injury, resulting in the need for medical services, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact. The deficient practice posed a risk if the facility failed to immediately notify the resident's responsible party of an accident, emergency, or injury that resulted in several fractures, and the facility provided false and misleading information to the Department. Findings include: 1. In record review, R1's medical record included documentation of a "...Occurrence Report," which documented, "Date of incident - 3/20/2025 Time of Incident - 08:45PM... Was family/resident's representative notified? - Yes If yes, person contacted O1 no response voicemail... Time notified: 03/20/25 8:45pm... Was attending physician notified? - Yes... Trask Mobile Time notified: 8:30PM.. went on voicemail..." The occurrence report provided was unsigned. However, another report was provided for review, and included the signatures of management personnel. 2. In record review, R1's medical record included the following "Narrative Charing," notes:<ul><li>3/21/2025 3:48 AM.. Follow up charting... Resident complained of pain in ribcage. Writer called and left message on emergency traks line and faxed traask to see about xray. No response as of yet. Resident was given prn for pain and was semi effective. Writer will follow up with trask in the morning. Signed by (E6)</li><li>3/21/2025 5:30AM Late Entry Entered On: 03/23/2025 2:28pm.. Fall Follow Up Contacted MPOA (O1) on 3/21/2025 at 5:37 and left message informing ... of the fall from previous night... Signed by (E5)</li><li>03/21/2025 05:44 AM Follow up charting Called trask emergency line 3-4 times, left message. Still awating response for next steps. Tylenol given to (R1) again for prn pain... is resting now. Tylenol seems to be effective. Will call trask again for next steps. Signed (E6)</li><li>3/21/2025 05:50 AM Follow up charting Traks answered and resident is scheduled for x-ray after 10am today. Signed (E6)</li><li>03/01/2025 (NOTE DATE) 8:30 AM Late Entry Entered On: 03/23/2025 2:31 PM Fall Follow Up Contacted MPOA and left message with update that we are expecting x-ray after 10am and that let us know if ... would like resident to be sent out to ER. This writer also checked on resident with Med Tech. Resident was resting at the time but Med Tech stated (R1) had exhibited pain when E6 checked on (R1) a short time ago. Signed (E5)</li></ul> 3. In record review E1's personnel record, (hired June 5, 2024, as a caregiver, and terminated from employment on March 20, 2025), included documentation titled, "Associate Action Plan for Improvement," that documented, "... General rules of Conduct: ... Failing to maintain acceptable standards of respect for residents.. And... Failing to follow safety rules and practices... 3/20/2025... On 3/20/2025, E1 was the Medication Technician on duty in the ... Neighborhood ... Resident (R1) experienced a fall and sustained injuries. E1 failed to complete an IR and did not follow through with calling EMS or Family or notifying oncoming staff that a fall occurred. This resulted in a delay of care for the resident... B. Improvement(s) Required: N/A Immediate Termination." 4. In documentation review, the facility's Incident Reporting policy, on page 106, documented, "... 4. Incidents are immediately reported to the resident's family/responsible party and physician. a. The date and time of such report to the family/responsible party and physician is documented in the narrative charting section of the resident record and documented on the incident report under notifications." 5. During an interview, E4 and E5 reported E1, E2, and E3 were working at the facility during the shift, when R1 fell. E4 and E5 acknowledged the facility's documentation of an Occurrence Report indicated R1's family was notified of the event at 8:45 pm on March 20, 2025. E5 reported (E5) contacted R1's representative (O1) at 8:30 am on March 21, 2025, and reported the fall and injury to O1.

Temporary Solution:

Correction was initialized after review of series of events leading up to resident’s transport to hospital. An investigation was initiated with team members who provided immediate care for the resident. Witness statements confirmed which staff member did not respond appropriately, and failed to contact the responsible party in a timely manner. A termination resulted from the investigation.
On 3/26/25, training for care staff specific to “What is an incident? And When to Create an incident report” was completed.
On 4/28/25 and 5/2/25, a mandatory retraining on Skills and Knowledge was conducted for care staff including “Assisted Living Emergencies and when to call 911”.

Permanent Solution:

Incident reports will be reviewed by the Executive Director and/or the Director of Health Services, or designee, within 24 hours of the incident. Incident reports will only be signed off when all data is accurately recorded.

Person Responsible:

Executive Director/Assisted Living Manager, Director of Health Services, Assisted Living Director, and Connections for Living Director

Facility Information

Inspection History

INSP-0130148

Summary:

INSP-0115542

Summary:

Deficiencies Found: 1

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0107723

Summary: