Inspection on 1/30/09 (13 pages) 1. QUALITY OF CARE: ... the facility failed to ensure a Foley catheter was secured at the insertion site when providing catheter care to prevent trauma on the urinary meatus for Resident #14, failed to ensure that indwelling urinary catheters were secured to prevent the potential of trauma to the urinary meatus for Residents 9 and 12 ... Resident #9... a. the plan of care updated 11/6/08 documented, “Problem onset 7/29/2007 Res (Resident) needs total assist with activities of daily living (ADL’s) Res is incont (incontinent) of bowel and bladder.” The care plan did not address the foley catheter. b. A Physician’s Order dated 1/5/09 documented, “Check leg band replacement q (every) shift.” d. On 1/26/09 at 5:10 p.m. CNA #1 and CNA #2 performed incontinent care after the resident had been incontinent of bowel. The CNAs rolled the resident back and forth while providing incontinent care for the resident. The resident had an indwelling urinary catheter. The catheter tubing was not secured to prevent the potential of trauma to the urinary meatus. e. On 1/27/09 at 10:00 a.m., LPN#1 changed the tubing and collection bag for the resident’s indwelling urinary catheter. The catheter tubing was not secured in any way after the LPN had completed the care for the resident... 4. Resident #14: ...had an indwelling foley catheter and was totally dependent on staff for personal hygiene. b. On 1/27/09 at 10:33 a.m. CNA #4 provided catheter care to the resident. CNA #4 did not secure the foley catheter tubing as the catheter tubing was cleansed from the insertion site outward. The resident stated, “…that hurts! …that hurts…” Pages 4-8.
Inspection on 7/3/08 (18 pages) 1. ACTIVITIES OF DAILY LIVING: ... the facility failed to ensure resident’s dentures were in place during a meal for Resident #1... Resident #1 required extensive assistance with activities of daily living. On 7/1/08 at 7:50 a.m., CNA #1 brought the resident’s breakfast tray into the room. The resident stated he just wanted a piece of toast and jelly. The CNA stated, “This toast is too hard (and rapped it against the side of the plate), I’m just going to feed him his (Raisin Bran) cereal.” A handwritten sign above the head of the resident’s bed read, “Please put [name of resident]’s teeth in and at night take them out.” (emphasis added) The resident was not wearing his dentures. The upper and lower plate dentures were in a cup in the bathroom. The CNA was asked if he would be able to eat better if he had his teeth in and the CNA stated, “Probably, but the night shift is supposed to put them in and they didn’t.” The CNA did not attempt to put the resident’s teeth in at any time during the breakfast meal. The resident consumed less than 25% of the meal. Pages 1, 3-4.
Inspection on 3/27/08 (20 pages) 1. MEDICATION ERRORS: . .the facility must ensure that it is free of medication error rates of five percent or greater...The medication error rate was 13.04%. Page 13.
Inspection on 9/6/07(93 pages) 1. ADMINISTRATION: ...Nursing Administration failed to ensure staff full assessed aggressive behaviors for causative factors and developed / revised and implemented interventions based on results of assessment to prevent resident to resident injuries for Resident #2 with history of aggressive behaviors. The failed practices resulted in immediate jeopardy which caused ... serious ... injury to Resident #1 who was struck in the face with a wheelchair footrest by Resident #2... Nurses Notes dated 8/17/07 at 8:35 p.m. documented, the resident was found lying in bed with 2 lacerations to the left side of her forehead. Resident #2 was sitting in the floor next to Resident #1’s bed. The Nurses Notes documented Resident #1 was sent by ambulance to the emergency room at 8:40 p.m. The Note documented the resident returned to the facility at 11:40 p.m. with bilateral blackened eyes, a scrape across the bridge of her nose, a bruise to the right side of her forehead, and 2 lacerations to the left side of her forehead. Top laceration approximately 1 inch long with 4 sutures. Bottom laceration approximately ½ inch long with 3 sutures. Pages 31-33.
Inspection on 5/18/07 (31 pages) 1. URINARY INCONTINENCE: ...the facility failed to ensure that incontinent care was provided in a manner to prevent the potential for Urinary Tract Infections for Resident #9... On 5/16/07 at 10:15 a.m., the resident had been incontinent of a large amount of loose yellow feces. CNA #1 wiped the anterior pubis area, but did not spread the labia and cleanse between the folds. The CNA applied a new incontinent brief, but prior to fastening it was asked by the surveyor to wipe down the middle of the labia fold with a clean washcloth. The CNA wiped the area with a clean cloth and obtained a large amount of yellow fecal material. Pages 9-10.
Inspection on 2/28/07 (12 pages) 1. STAFF TREATMENT OF RESIDENTS: ...the facility failed to ensure an allegation of neglect was thoroughly investigated, interviews were conducted with staff, other residents and/or family members, protection of the resident from further potential abuse, staff was knowledgeable of what to report and when to report allegation of abuse and failed to report allegations of abuse to the Office of Long Term Care and/or any other agencies as required by law. Page 2.
