Following are some of the deficiencies found during inspections of this nursing home on 2/19/09, 1/16/09, 8/21/08, 5/23/08 and 4/4/08. These Reports and others (2/22/08 – 11 pp, 6/29/07 – 11 pp, 5/25/06 – 22 pp, 9/9/05 – 2 pp and 8/9/05 – 13 pp) can be found at www.arknursinghomeinspectiondeficiencies.com.
Inspection on 2/19/09 (4 pages) 1. PRESSURE SORES . . . the facility failed to ensure the physician was consulted timely to prevent the delay in treatment to prevent the potential for further skin breakdown for Residents #3 and #5 who had pressure sores. . . Resident #3 . . . The Quarterly MDS dated 11/21/08 documented the resident had . . . no pressure sores. The Narrative (Resident Assessment Protocol) Summary for Pressure Ulcers dated 9/8/08 documented, Pressure Ulcer RAPS Triggered: Yes, Care Plan: Yes See Incontinence.” Nurse’s Notes dated 1/17/09 at 10:10 p.m. documented, “[name] ER [emergency room] states [resident] admitted for dehydration [and] Sepsis.” Nurse’s Notes dated 2/1/09 at 3:05 p.m. documented, “. . . Open areas to both heels, [no] drainage or bleeding noted . . .” There was no documentation the physician was consulted or treatment was initiated to the open areas on the resident’s heels. . . As of 2/18/09 at 3:30 p.m., there was no documentation in the Nurse’s Notes or the physician orders that indicated the physician had been consulted for intervention on the open areas of the resident’s heels. . . On 2/18/09 at 3:36 p.m. . . . The treatment nurse was shown the Nurse’s Notes from 2/1/09 which documented the open areas to the resident’s heels. She stated, “I was not aware of that.” . . . On 2/19/09 at 4:12 p.m., the Director of Nursing stated, “There are no 24-hour nurse reports from 2/1/09, 2/2/09 or 2/3/09. . . The DON was shown the Nurse’s Notes for the resident which documented the open areas to both heels. The DON denied knowing about the open areas to the heels . . . Pages 1-4.
Inspection on 1/16/09 (19 pages) 1. HOUSEKEEPING / MAINTENANCE . . . On 1/14/08 at 11:15 a.m., on the 100, 200, 300 and 400 halls, the handrails had a thick buildup of light rolls of dust balls, the dust balls were approximately one inch thick on the handrails throughout the facility. Pages 2-3.
2. PRESSURE SORES . . . Resident #12 had a diagnosis of history of pressure sores. . . The admission assessment dated 11/20/08 documented the resident’s right heel was red and had a diagnoses of History of Pressure Sores . . .The Plan of Care dated 12/18/08 documented, “Heel Protectors. Bridge Heels.” On 1/15/09 at 3:50 p.m. . . . the resident’s heels were resting directly on the bed . . . On 1/15/09 at 4:35 p.m., the Director of Nursing stated, “Pillows are all they’ve been using.” Pages 5-7.
3. LABORATORY SERVICES . . . On 1/13/09 at 10:30 a.m., the resident’s clinical record was reviewed and there were no routine labs ordered to monitor the therapeutic values and/or the adverse effects for Coumadin, Depakote, Potassium, Dilantin or Lasix. Pages 16-18.
Inspection on 8/21/08 (18 pages) 1. ACCIDENTS AND SUPERVISION: . . . The facility failed to ensure adequate supervision was provided to ensure the staff member responsible for van transportation demonstrated safe driving skills and safe transfer skills for transportation of Resident #2 who sustained a fall while being off-loaded from the van. . . This . . . resulted in harm and injury to Resident #2 when the lift was in the down position when off-loading the resident, causing the resident to fall from the van. Pages 11-12.
Inspection on 5/23/08 (4 pages) 1. QUALITY OF CARE: . . .The facility failed to ensure all areas of the perineum were cleansed during incontinent care for Resident #5 who [was] incontinent. Page 1.
Inspection on 4/4/08 (9 pages) 1. QUALITY OF CARE . . . On 4/1/08 at 12:12 p.m. CNA #1 put on latex gloves to dress the resident. There was a sign above the Resident’s bed that documented “Allergic to Latex.” [emphasis added] The CNA stated the gloves were latex powder-free gloves. The surveyor stopped the CNA prior to her touching the resident. The resident had a pair of latex-free gloves in his beside dresser drawer, which the CNA got out of the drawer and put on. CNA #2 came into the room to help CNA #1 get the resident up. She had latex gloves on. CNA #2 was stopped by CNA #1 from using the latex gloves and CNA #2 left the room to get latex-free gloves. Upon return to the room, CNA #2 stated, “LPN #1 told me to go ahead and use these gloves.” Again, the CNA was stopped from using latex gloves to care for the resident. Pages 1-2.
