Following are some of the deficiencies found during inspections of this nursing home on 12/31/08, 11/14/08, 8/13/08, 3/4/08 and 1/16/08. These reports and others (4/10/08 - 9 pp Complaint and 4/10/08 - 9 pp Revisit) can be found at www.arknursinghomeinspectiondeficiencies.com.
Inspection on 12/31/08 (16 pages) 1. ACTIVITIES OF DAILY LIVING: . . . the facility failed to ensure the mons pubis area, underneath the folds of the abdomen or between the crease of the leg on the right side where stool had leaked from the colostomy bag was cleansed for Resident #8 . . . Pages 2-3
2. PRESSURE SORES: . . the facility…failed to ensure an excoriated area was cleansed and barrier cream was applied after a resident had been exposed to a urine saturated brief due to a leaking catheter for Resident #5 . . . Page 5.
Inspection on 11/14/08 (63 pages) 1. PRESSURE SORES: . . the facility failed to ensure all areas of the perineum and groin were cleansed, rinsed and dried after providing incontinent care for Resident #7. . . at risk for skin breakdown. . . Pages 14-15.
2. NUTRITION: . . . the facility failed to ensure that interventions to prevent continued weight loss and to promote weight gain were promptly developed, implemented, monitored, and re-evaluated for Resident #4, #10, #15 and #16 . . . who experienced severe, unplanned weight losses. Page 29.
3. MEDICATION ERRORS: . . the facility failed to ensure that the medication error rate was less than 5%. . . . The medication error rate was 11.36%, Page 41 4. PREVENTING SPREAD OF INFECTION: . . the facility failed to ensure all soiled gloves were removed after incontinent care before applying a clean brief, covering the resident with a sheet and pulling up the residents side rail for Resident #7 . . . Page 46-47.
Inspection on 8/13/08 (16 pages) 1. ACTIVITIES OF DAILY LIVING: . . .the facility failed to ensure all areas of the perineum and groin were cleansed when providing incontinent care for Resident #3 and failed to ensure showers / bathing were provided timely to promote a good hygiene for Resident #9 . . . Page 3.
2. PRESSURE SORES: . . the facility failed to ensure a resident was assessed and provided incontinent care at least every two hours to reduce the potential for skin breakdown for Resident #2 and #3 . . . who were at risk for pressure sores. Page 9.
Inspection on 3/4/08 (51 pages) 1. PRESSURE SORES: . . the facility failed to ensure necessary care and treatment to promote healing of pressure ulcers and prevent development of new pressure ulcers was provided to Resident #6 and #7 with pressure ulcers . . . as evidenced by failure to conduct weekly skin assessments in accordance with the Plan of Care, failure to document measurements of pressure ulcers to allow healing or deterioration to be accurately assessed, failure to implement care planned or physician-ordered pressure relief interventions immediately upon discovery of pressure ulcers and consistently thereafter, failure to reassess the resident's nutrition and hydration needs in a timely manner after pressure ulcers were identified, failure to consistently document the resident's nutritional intake and the provision of nacks/supplements and failure to apply a pressure ulcer dressing in accordance with the physician order. Pages 14-15.
2. ACCIDENTS AND SUPERVISION: . . .the facility failed to ensure interventions were developed and implemented to prevent further falls for Residents #2, #5, #6 and #8 with a history of falls . . . The failed practices resulted in actual harm to Resident #5, who sustained femoral and humeral fractures as a result of a fall. . .Page 27.
3. NUTRITION: . . . the facility failed to ensure interventions to prevent nutritional deficits and weight loss were implemented for Residents #2 and #7 . . . who experienced unplanned weight loss . . . as evidenced by failure to reassess nutritional needs when nutritional laboratory values declined or pressure ulcers were identified, failure to communicate the Registered Dietician's recommendations to the physician and failure to implement the recommendations and failure to consistently monitor and document nutritional intake. The failed practices resulted in a pattern of actual harm to Resident #7, who experienced a severe weight loss and was hospitalized with a Stage III decubitus, uncontrolled Diabetes Mellitus and Acute Renal Failure. . . Pages 38-39.
Inspection on 1/16/08 (39 pages) 1. ACTIVITIES OF DAILY LIVING: . . . the facility failed to ensure urine was cleansed from all areas of the resident's skin during incontinent care for Resident #8 . . . Page 6.
2. PRESSURE SORES: . . the facility failed to ensure skin was monitored for breakdown for residents with or at risk for pressure ulcers, failed to ensure identified skin breakdown was assessed, that areas of breakdown were monitored, that the physician was immediately consulted for treatment orders for each area of breakdown or when areas deteriorated or that planned interventions were implemented to ensure healing of pressure sores for Residents #4 and #8 . . . with pressure ulcers. The failed practices resulted in patterns of actual harm to Residents #4 and #8 who developed additional pressure ulcers or deterioration of existing pressure ulcers. The facility also failed to ensure clean technique was followed during wound care, to prevent potential infection of existing pressure ulcers for Residents #8 and #9 . . . with pressure ulcers. Pages 7-8.
3. NUTRITION: . . . the facility failed to ensure nutritional interventions were implemented to maintain nutritional parameters for Resident #4. . . who experienced a weight loss. This failed practice resulted in a pattern of actual harm to Resident #4 who experienced a severe weight loss. . . Page 23.
