Inspection Reports for
The Bridge at Lawrenceville

The complaint investigation revealed that the resident had signed DNR documents, but the facility coded her as full code due to missing or unsigned POLST forms. Interviews with the resident, administrative staff, admissions director, social services director, and administrator highlighted procedural gaps and miscommunication regarding advance directives and physician orders.

The facility failed to update the medical record to reflect the resident's change in code status to DNR, resulting in potential denial of the resident's or representative's opportunity to direct health care. Interviews and record reviews revealed issues with documentation, communication, and processing of advance directives and POLST forms.

The facility was found deficient in ensuring PASARR Level II evaluations for residents with serious mental illness, developing comprehensive care plans for oxygen therapy, maintaining safe water temperatures, administering oxygen therapy as ordered, and implementing proper infection prevention and control practices including storage of respiratory supplies and hand hygiene during medication administration.

The complaint investigation focused on the facility's failure to control a COVID-19 outbreak, including inadequate testing, contact tracing, and infection prevention practices. The outbreak began on August 2, 2023, resulting in 28 residents and 8 staff testing positive, 3 hospitalizations, and 1 death. The facility did not follow CDC and Georgia Department of Public Health guidance for broad-based testing and failed to maintain proper documentation of testing orders and results.

The facility failed to ensure accurate assessments for residents, appropriate treatment and care, safe respiratory care, and effective infection prevention and control. Specifically, the facility did not follow CDC and state guidelines for COVID-19 outbreak testing and contact tracing, resulting in 28 residents and 8 staff testing positive, 3 hospitalizations, and 1 death. The Infection Preventionist role was inadequately performed, and documentation of testing orders and results was incomplete or missing.

The facility failed to ensure resident wishes regarding advance directives were properly documented and communicated, failed to provide appropriate pressure ulcer care and nutritional support for a resident with wounds, failed to develop an adequate pain management plan for a resident with chronic pain, and failed to ensure proper infection control practices including COVID-19 precautions and glucometer disinfection.