Inspection on 2/27/09 (8 pages) 1. QUALITY OF CARE: . . .the facility failed to ensure the labia was spread and cleaned and a back to front motion was not used during Foley catheter care for Resident #7. . .a. A physician order dated 8/27/07 documented to provide Foley catheter care each shift. b. On 2/24/09 at 10:00 a.m., CNA #1 provided Foley catheter care. CNA #1 used a washcloth and soap, and with a back to front and front to back motion washed the left and right groin and over the labia lips three times and did not spread the labia and cleanse the labia folds. On 2/24/09 at 2:00 p.m., CNA #1 stated, “I shouldn’t have washed back and forth.” Pages 1-2.
2. PRESSURE SORES: . . the facility failed to ensure nursing staff were informed of the identification of a pressure ulcer so treatment could be initiated for Resident #1. Page 2.
3. SANITARY CONDITIONS: . . . the facility failed to ensure staff washed their hands after handling soiled items and before handling clean dishes, utensils or food to prevent the potential for cross-contamination. Page 6.
Inspection on 3/28/08 (28 pages) 1. NUTRITION:…the facility failed to ensure nutritional interventions that were implemented to maintain nutritional parameters were assessed for its effectiveness and/or revised for Resident #8 who experienced severe weight loss. Pages 19-20.
Inspection on 6/29/07 (18 pages) 1. PRESSURE SORES: . . the facility failed to ensure that residents were turned and repositioned in a timely manner to decrease the potential for skin breakdown for Residents #3 and #5 and failed to cleanse urine and/or feces from all areas of the perineum / skin to decrease the potential for skin breakdown for Residents #2 and #7 . . Pages 2-3.
2. INFECTION CONTROL – LINENS:…the facility failed to ensure that linens and/or incontinent briefs contaminated with urine or feces were not placed on resident furniture or equipment to decrease the potential for the spread of infection . . . Page 17.
Inspection on 3/19/07 (51 pages) 1. STAFF TREATMENT OF RESIDENTS: . . .the facility failed to prevent neglect as evidenced by the facility’s failure to develop and implement written policies and procedures to ensure protection for . . .residents affected by wanderers . . . The failed practice resulted in actual harm [fear] for Resident #1. Page 1
Inspection on 2/26/07 (5 pages) 1. QUALITY OF CARE: . . .the facility failed to ensure that the foley catheter was secured to prevent the potential for trauma to the urinary meatus, gloves were changed and soap and water was used during incontinent care for Resident #2. Page 1 2. URINARY INCONTINENCE: . . .the facility failed to ensure that there was a medical necessity for the continued use of foley catheter for Resident #2. Page 3
Inspection on 11/7/06 (13 pages) 1. STAFF TREATMENT OF RESIDENTS: . . .the facility failed to ensure an injury of unknown origin was investigated to rule out abuse for Resident #1. Pages 3-4
2. QUALITY OF CARE: . . .the facility failed to ensure Resident #5 . . . who experienced skeletal fractures and/or had physician orders for as-needed pain medication was assessed for pain and provided with physician-ordered pain management. . . a. Nurse’s Notes dated 10/13/06 documented: “. . . bruising noted to left leg, swollen, warm to touch, [physician] called, waiting on return call. . .” At 10:15 a.m., the Nurse’s Notes documented a physician order was received to obtain a mobile x-ray of the resident’s left hip and knee. b. An Incident / Accident Report dated 10/13/06 documented: “. . .purple/yellow/green bruise to back of left leg. Knee swollen, warm . . . to hospital for evaluation. Lt. [left] Fx. [fracture] knee immobilizer. Follow up appointment with orthopedic.” . . . d. Nurse’s Notes dated 10/13/06 at 8:30 p.m. documented: “. . . new order Lortab 7.5/500 one tablet every 4-6 hours PRN [as needed]. Call and schedule follow up appointment Monday 10/16/06 . . .” e. There was no documentation in the Nurse’s Notes from 10/13/06 through 10/16/06 that pain assessments were completed. . .f. The October 2006 Physician Order sheet documented an order (originally dated 4/26/06) for Vicodin 5/500 one tablet per mouth every 6 hours as needed for pain. A physician’s telephone order dated 10/13/06 at 10:00 p.m. documented: “Lortab 7.5/500 one tablet every 4 to 6 hours PRN Pain. Follow up appointment (schedule) on Monday 10/16/06.” g. Patient Education Materials dated 10/13/06 from the hospital documented: . . . Patella Fracture . . . You have a fracture (break) of the patella bone “kneecap.” This causes pain, swelling and sometimes bruising. . . i. As of 11/7/06, there was no documentation on the October 2006 or November 2006 Medication Administration Records (MAR’s) that any pain medication was administered to the resident from 10/13/06 through 11/7/06 . . . Surveyor: “Do you think that [resident] experienced any pain and needed pain medication?” Director of Nursing: “Yes, I’m sure she did have pain and should have gotten some medication.” Pages 10-13.
Inspection on 7/28/06 (14 pages) 1. HOUSEKEEPING/MAINTENANCE:…the facility failed to ensure window screens were attached and in good repair, resident equipment was not rusted, the glass in doors was not cracked, thresholds, floors and air vents were not dirty, baseboard were attached to the wall, water faucets did not drip, chairs were clean and floor tiles were not cracked. Page 4.
