Macon Elder Abuse Lawyer

There is a tremendous amount of government-produced data regarding Georgia nursing homes, senior living facilities, assisted living communities, assisted living facilities, hospices, long-term care facilities, and other facilities that are supposed to provide medical care for elders. Your elder abuse lawyer must understand and use reports and investigations performed by agencies such as Medicare and the Georgia Department of Community Health (DCH).

What is the most troublesome nursing home in Macon, GA? There are instances in which every nursing home shows insufficient care and attention to patients. However, some nursing homes show a pattern of mistreatment.

A Case Study In Available Data Regarding a Macon, Georgia Elder Rehabilitation and Long-Term Care Facility

Fountain Blue Rehab and Nursing, which is located at 3051 Whiteside Road, Macon, GA 31216, has demonstrated a pattern of insufficient health care for residents. Here is a sample of the problems that we have observed on the medicare.gov site regarding this care facility:

• Based on record review, review of hospital records, review of the facility Weight Policy and Procedure(no date) and Change of Condition policy (updated ,[DATE]) and staff interviews, the facility failed to notify the Physician and Registered Dietician of a significant weight loss for one resident (R#1) who had a 20 percent (%) loss in two months. The facility also failed to notify the Vascular Surgeon of the deterioration of the surgical wound for that same resident (R#1) who was sent to the hospital and expired due to complications [MEDICAL CONDITION] from his wound of a sample of nine residents reviewed for a change in condition. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility’s Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility’s non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility’s Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound.  R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident’s wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon’s (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon’s office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident’s weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident’s intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident’s meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident’s weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483. 10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483. 70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of L. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include:  Review of the facility Weight Policy and Procedure (no date) revealed that residents were weighed a minimum of two times each month. The Food and Hydration Aide weighed residents within 24 hours of admission to the facility, then weekly for 4 weeks and twice monthly thereafter. Weight changes were calculated within 48 hours of obtaining body weights through the use of a computer program. The Food and Hydration Aide notified the Registered Dietician (RD) of residents with a significant weight change via the Weight, Food and Hydration Notification form. The RD assessed each resident with a significant weight change, made appropriate recommendations to physicians and updated the resident’s plan of care. Review of the facility Change of Condition policy (revised ,[DATE]) revealed that any staff member who noticed a resident status change would immediately notify the appropriate licensed personnel. After assessing the resident, the licensed personnel would contact the Physician immediately regarding the status change. When the Physician was unavailable, the alternate would be contacted. Notification of the appropriate individuals was to be documented in the medical record and the 24 hour report and followed for 72 hours. Life threatening situations may warrant immediate transfer to the hospital. The Director of Nursing (DON) would be kept informed of all condition changes and would share those with the Administrator on a daily basis. Review of the Admission Record, dated [DATE], and the [DIAGNOSES REDACTED].#1 (R#1) had the following [DIAGNOSES REDACTED]. Review of the physician’s orders [REDACTED]. Review of the Treatment Administration Record (TAR) for February 2019 revealed that there was no evidence that the treatment had been completed on [DATE], [DATE], [DATE], [DATE], or [DATE]. Record review revealed a change in the Physician Order, from the surgeon (Physician EE), on [DATE] to Santyl ointment, apply to left stump topically every, day shift for wound. Clean left stump with normal saline, pat dry, apply on ointment to eschar and left edge, wet to dry in the middle of wound, cover with dry dressing daily. Record review of Progress Notes dated [DATE] revealed that the resident stump wound was declining, had an odor, which the resident stated makes him sick on his stomach. Resident has a low-grade fever. Treatment to left stump ongoing. There was no evidence that Physician CC was notified of the wound decline. Review of the Hospital discharge order sheet, dated [DATE], He has a special matrix dressing inside. Wound vac should be set at 75. DO NOT remove the vaseline gauze and dressing beneath it. Wound care nurse to change the wound vac on MWF (Monday, Wednesday, Friday). Please send dressing change supplies to the office on [DATE] for wound vac changes. R#1 was readmitted to the facility on [DATE] (Saturday) with a Physician order [REDACTED]. The resident’s wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room, on [DATE], without a roommate due to the complaints of the foul smell from the wound.  Review of the Vascular Surgeon’s (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the surgeon’s office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending Physician CC (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. An interview with the Administrator on [DATE] at 4:56 p.m. revealed that the Social Worker, who is a former Ombudsman and a former Administrator (without an active license) is responsible for arranging transportation for the residents. The Administrator states that the facility has had difficulty with the transportation company that may not send appropriate transportation for the residents. An interview on [DATE] at 4:47 p.m. with Physician EE (Vascular Surgeon), revealed that he placed the [DEVICE] to promote the healing of R#1 surgical site. When asked what effect if any, if the [DEVICE] dressing was not change, he stated that not changing the sponge every 3rd day, would prevent seeing signs of infection and wound deteriorating. The [DATE] was a critical appointment to access the progress of healing, but the resident was a no show for this appointment and the facility declined the appointment for [DATE]. The facility had not communicated with him on the condition of the wound nor was he notified that staff did not know how to change the wound vac. He further revealed that if the facility had contacted him then would have help the facility to facilitate the use of the [DEVICE]. He revealed that the former Treatment Nurse and the facility SW had contacted his office as needed in the past. Review of the facility Monthly Weight Record (which not available in the electronic record) revealed that R#1’s weight on [DATE] was 133 pounds, on [DATE] his weight was 118 pounds and on [DATE] was 106 pounds. The February to [DATE] revealed R#1 had a 11% weight loss; March – [DATE] was a 10% weight loss; and February -[DATE] revealed 20% overall weight loss from the date of returning from the hospital on [DATE] to being readmitted on [DATE] to the hospital. Review of the Progress Notes Nutrition/Dietary Note dated [DATE] revealed this was the only entry for the current year (2019). The Registered Dietitian (RD) noted that R#1 had a wound on his left stump and a stage 1 on his sacrum. It is also, noted that resident was receiving Health Shakes, multivitamins (MVI) and Pro-Stat to promote healing of wounds. He does have bilateral AKA. No new weight on chart at this dated. Could not finish nutritional assessment. Review of the resident’s intake record revealed that the resident had begun with poor intake in late February 2019 and then throughout [DATE] his intake was ,[DATE]% per meal and regularly refused his meals. Review of the Wound doctor (Physician FF) note dated [DATE] revealed the resident now had a Stage IV pressure wound to his sacrum. The wound measured 10X5X2 centimeters with thick adherent devitalized necrotic tissue. The facility could not provide evidence of skin assessments from [DATE] except for the Wound Physician FF’s wound notes.  During an interview with the RD on [DATE] at 11:04 a.m. revealed that she was not aware that R#1 was not eating and that she received her wound stage from the former treatment nurse. She further stated that she comes to the facility on ce a month and physically sees each resident. When she came in March, the resident was still able to feed himself. The only concern she had at that time, he was a bilateral AKA and that his left AKA was not healing. She had not received information that the resident had developed a Stage IV pressure ulcer or of his weight loss and diminished intake. An interview with Physician CC (Medical Director) on [DATE] at 4:40 p.m. revealed that he could not recall if he had been notified of the weight loss or of the development of a Stage IV pressure ulcer. Physician CC did confirm giving an order on [DATE] for [MEDICATION NAME] and [MEDICATION NAME].
• A subsequent interview on [DATE] at 2:58 p.m. Physician CC revealed that on [DATE] he saw the resident and started the resident on oral [MEDICATION NAME] until the resident could be seen by the surgeon on [DATE]. He could not recall if there was a strong odor when seeing the resident on this visit. The resident missed that appointment due to transportation. On [DATE], he gave the order to send resident to emergency room (ER) for evaluation. Physician EE, the surgeon, was on call that evening. An interview with the Administrator on [DATE] at 3:51 p.m. revealed that the previous DON was responsible for training staff and agency nurses. He revealed that the Agency was responsible for training agency nurses, although the staff nurses were responsible for showing the agency nurses how the facility does things at this facility. He revealed not having knowledge that weekly wound assessment and wound treatments were not being done. An interview on [DATE] at 4:47 p.m. with R#2, who was R#1’s roommate, revealed that the R#1 stump became infected and the odor was bad. He had complained to staff and the resident was moved to another room. An interview with the Administrator on [DATE] at 4:21 p.m. revealed that morning meetings had begun, again, on [DATE] and was held to discuss issues pertaining to the facility. The clinical meetings were held by the DON and that he did not attend the clinical meetings. He did get a summary of the number of people who were discussed but not their names. An interview on [DATE] at 9:43 a.m. with Certified Nursing Assistant (CNA) QQ revealed that her first day at the facility was [DATE] and she was assigned to R#1. She was providing ADL (activities of daily living) care to the resident and found a wound on his sacral area the size of an apple. She reported it to an agency nurse, who stated this had not been reported to her. She revealed that the Wound doctor (Physician FF) was in the building and the agency nurse asked her to see the resident’s wound. She further revealed that R#1 had been in a multi-bed ward but was moved due to his roommates complaining about the odor. She further stated there hadn’t been a wound nurse for a couple of weeks. She revealed that the resident had gone from feeding himself to needing assistance to eat. She further revealed that she had reported that the resident wasn’t eating to the agency nurses and to LPN AA. An interview with R#8 on [DATE] at 11:58 a.m, a former roommate of R#1 (who was in a multiple bed ward at that time), revealed that the R#1 had a smell and some sort of machine to this leg. The smell was weird and strong. He had reported it to one of the nurses then R#1 was moved to another room. An interview on [DATE] at 10:14 a.m. with CNA RR who revealed that about one to two weeks after R#1 returned from the revision, he became delusional. He was constantly turning on his call light then saying outlandish things such as he needed to get up and walk. The smell from him was like something rotten, decaying. The smell was so bad that you needed to open the windows. The treatment nurse would spray a disinfecting spray in the room. The wound started smelling after the wound vac was placed and the contents in the vacuum container looked like pus. He was moved out of the ward to another room due to smell and then he stopped eating. She had reported it to LPN AA who told them just to give him health shakes but even with assistance he wouldn’t eat much. She revealed that on [DATE] that LPN AA and the agency nurse were working with his wound vac, attempting to figure out what to do and it wasn’t working. She further revealed that the resident had a sunken look, his lips were dry and cracked.  An interview on [DATE] at 12:04 p.m. with the current DON revealed that the wound suction canister was full. This was the first time he actually seen the wound, which was on [DATE]. He further stated that Physician CC was dragging his feet about sending the R#1 to the hospital. We (SW) called the vascular clinic to get assist with sending the resident out. An interview with the SW on [DATE] at 2:00 p.m. revealed that she had contacted Physician EE’s office seeking help for R#1. She stated that Physician CC would not give an order to send the resident to the hospital and she was very concerned about the resident. She further stated that staff had been trying to get Physician CC to send the resident to the ER because he was getting worse, his wound smelled so badly, and the resident was becoming more confused. She confirmed that the resident was transferred to a semi-private room, without a roommate, on [DATE] due to complaints of the odor by the resident’s roommates. The SW stated she may have mentioned to the Administrator regarding Physician CC refusing to send the resident to the ER but since he was not clinical, she may not have gotten into the details about the situation.
• Based on observ ation, record review, and resident/staff interviews, the facility failed to ensure a clean, comfortable and homelike environment as evidenced by brown/black staining on tiles, black buildup, chipped and missing paint on walls and ceiling, and a loose vent in the ceiling in two of three common shower rooms (both on 100 hall); and dirt and debris buildup on three resident wheelchairs (R#1, R#2, and R#3), one scoot chair, and one stand-up lift. Findings include: Observation on 10/14/2020 at 9:35 a.m. revealed a scoot chair, located near room 117, that had dirt buildup on the wheels of the chair. Observation on 10/14/2020 at 9:43 a.m. in the common shower room on 100 hall near nurse station 2 (Shower Room #1), there was black staining on the floor leading into the shower, black build up on the tile in the shower, and  black and brown substances around the toilet. There was also a closet like area in which the door was open and there was brown staining on the door. There was also black build up on the floor in the closet area with rusting noted at the bottom of the doorframe. Observation on 10/14/2020 at 9:48 a.m. in Shower Room #2 on 100 hall there was dark buildup noted in the tile on the floor and in the shower, buildup on the shower walls, missing tile in the shower, missing baseboard and cracked tile at corner near closet door, peeling paint in the ceiling, loose vent in ceiling when entering the shower room, and buildup on the floor with chipped paint and a hole in the lower wall behind the door. Observation on 10/14/2020 at 11:30 a.m. of R#1’s wheelchair, dirt buildup was noted on wheels and undercarriage. During an interview at this time, R#1 reported that the wheelchair had not been cleaned in 5 or 6 months. Observation on 10/14/2020 at 11:50 a.m. of R#2’s wheelchair revealed hair and dirt buildup on undercarriage and wheels of the wheelchair. During an interview at this time, R#2 reported having the wheelchair for at least two months and denies that the wheelchair has ever been cleaned. R#2 further reported that the shower room floors and walls are always dirty and does not like going into the shower room. Observation on 10/14/2020 at 12:14 p.m. of R#3 sitting in wheelchair with dirt and hair build up noted on the wheels and undercarriage of the wheelchair. During an interview at this time, R#3 reported that the wheelchair has only been washed one time in the past year. It was further reported that the shower rooms are nasty. R#3 expressed that there are always black markings on the floor and sometimes there is bowel movement in the shower and staff have to clean  this up before giving R#3 a shower. A tour of shower rooms on 100 hall were conducted on 10/14/2020 at 11:07 a.m. with the Director of Housekeeping who reported that Certified Nursing Assistants (CNA) are responsible for keeping the shower room floors cleaned and housekeeping staff only comes in once a day to mop and touch up the area. The black stains on the floor, brown substance on closet door, and buildup in the shower was confirmed. During tour of the second shower room on 100 hall the Director of Housekeeping confirmed the buildup on the floors and on the tile in the shower, broken tile in the shower, chipped and peeling paint in the ceiling, and the hanging vent in the ceiling. The Director of Housekeeping reported that any repair issues should be documented in the maintenance book that is located at each nurse station for the maintenance department to follow up. An interview was conducted with Licensed Practical Nurse BB on 10/14/2020 at 11:15 a.m. who reported that CNA staff should be washing the shower bed and shower chairs between each resident and the nurses are supposed to check that the shower rooms are clean. During an interview with Registered Nurse (RN) Unit Manager DD on 10/14/2020 at 12:48 p.m. it was reported that CNAs are to clean up behind themselves when using the shower room and housekeeping staff is responsible for cleaning the shower room. RN Unit Manager DD further reported that she was aware of the broken tiles in the shower room and they had been reported to maintenance before, but she was not sure when the notification was done. She further reported that wheelchairs are cleaned the last Thursday of every month or as needed.

Fountain Blue advertises that it provides rehabilitation, medically complex and long term care units. What we see in the Medicare reports regarding Fountain Blue are nurses and caregivers continually asking physicians to upgrade the care and urgency of care that is given to patients, but the doctors and physicians refuse to act on the complaints. Refusing to provide care in the face of an immediate and known risk is elder abuse. The Medicare reports of the investigation of Fountain Blue showed that the medical care provided to patients was clearly below any reasonable expectations. The excepts above are just a sample of the elder and senior care problems that existed within Fountain Blue. There are numerous other reports on the Medicare site alone.

Family members with loved ones in a facility such as Fountain Blue Rehabilitation in Macon, GA should exercise a heightened level of diligence to make sure that the medical care their loved one receives is adequate.

Another Case Study in Elder Abuse in Macon, GA:  ARCHWAY TRANSITIONAL CARE CENTER

Archway Transitional Care Center is located at HOUSTON AVENUE MACON, GA 31206. The information provided here is from a report produced from a inspection report dated  4/7/2021. This is an interesting inspection report because it highlights several of the problems that we face in addressing the care provided by nursing homes and senior living facilities.

•  483.12(c)(1)(4) Reporting of Alleged Violations §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
•  This REQUIREMENT is not met as evidenced by: Based on record review, review of the facility policy titled “Abuse Prohibition,” and staff interview, the facility failed to report resident-toresident abuse involving three residents (R) (#1, R#2, and R#3) reviewed for abuse. Findings include: Review of the facility policy titled “Abuse Prohibition” updated February 2020 revealed: 2. Identification of possible abuse, neglect, or exploitation d. identification of coverage and responsibility. Patients in our center will not be subjected to abuse by anyone (including but not limited to: … other residents.) Any person observing any abuse, …, must immediately report it the Administrator … The policy does not include information related to reporting to the State Survey Agency. R#1 had an Admission Minimum Data Set (MDS) dated 3/16/21 documenting a Brief Interview of Mental Status (BIMS) score of 9, indicating mild cognitive impairment. Section E – Behaviors revealed delusions, physical and verbal behaviors, puts others at risk for injury, intrudes on others privacy, disrupts care/living environment, and wanders. R#1 had diagnoses including paranoid schizophrenia, delusional disorder, dementia with behavioral disturbances, anxiety, and Alzheimer’s disease. R#2 had an Annual MDS dated 2/2/21 documenting a BIMS score of 15 indicating no cognitive impairment. Section E – Behaviors revealed no behaviors. R#2 had diagnoses  including major depressive disorder and psychosis. R#3 had a Quarterly MDS dated 1/27/21 documenting a BIMS score of 3, indicating severe cognitive impairment. Section E – Behaviors revealed rejection of care. R#3 had diagnoses including paranoid schizophrenia and dementia with behavioral disturbances. Review of a Nurse’s Note dated 3/13/21 revealed R#2 came to the nurse’s desk and stated R#1 attacked her. Staff escorted R#1 out of the room and assessed R#2 finding no injuries. Review of Nurse’s Note dated 3/26/21 revealed R#3 approached R#2 in the hallway, grabbed her by the hair and slapped her in the face. R#2 then threw a glass of water at R#3. There is no evidence that the incidents were reported to the State Survey Agency. Interview on 4/7/21 at 1:04 p.m. with the Administrator and Assistant Director of Nursing (ADON) confirmed neither incident was reported to the State Survey Agency. They did not deem the incident to be abuse because R#1 and R#3 have these behaviors but there was no intent. There were no concerns identified with the actions of the facility related to resident care, in response to the resident-to-resident abuse.

This incident at Archway Transitional Center in Macon, GA is an incident in which a violent crime was perpetrated upon a resident of a nursing home by another resident. It illustrates the importance of having sufficient staffing present to monitor the interactions of residents.

Do you want to learn more about the patient-to-patient violent crime risks at nursing home facilities? Visit the Atlanta Journal Constitution’s coverage of this problem. The AJC has done a great job of provided in-depth coverage of the nursing home abuse problem in Georgia.