Following are some of the deficiencies found during inspections of this nursing home on 11/13/08, 9/26/08, 6/17/08, 12/14/07 and 9/28/07. These Reports and others (1/26/07 – 16 pages, 9/5/06 – 5 pages, 6/22/06 x 2 – 10 pages and 6/22/06 12 pp, 5/11/06 x 2 – 12 pp and 5/11/06 8 pp, 4/26/06 – 18 pp, 4/06/06 – 12 pages and 2/15/06 – 51 pages) can be found at www.arknursinghomeinspectiondeficiencies.com.
Inspection on 11/13/08 (10 pages) 1. PRESSURE SORES: . . The facility failed to ensure that staff informed the LPN and/or treatment nurse when a wound dressing needed to be replaced . . . and wound care was provided as per physician orders . . . Page 1.
Inspection on 9/26/08 (53 pages) 1. DIGNITY: The facility failed to ensure that staff spoke to residents respectfully and/or did not yell at residents for Residents #18 and #25 that had made accusations of verbal abuse. Page 6
2. ACTIVITIES OF DAILY LIVING: . . .The facility failed to ensure the penis and mons pubis was cleansed when providing incontinent care, the anal area was not cleansed using a back to front motion and a clean incontinent brief was used after incontinent care had been for provided for Resident #2 . . ., failed to ensure that incontinent care and/or toileting was provided at least every two hours and cleansed the mons pubis, labia, buttocks, and thighs when providing incontinent care for Residents #6 and #24. Page 9.
3. PRESSURE SORES: . . The facility failed to ensure that ace wraps were removed and the skin integrity assessed at least daily to prevent the potential for deterioration in skin integrity for Resident #9 whose legs were wrapped with ace bandages and was at risk for skin breakdown. . . failed to ensure incontinent care was provided at least every 2 hours to prevent the potential for skin breakdown for Resident #6 who had a pressure sore on the sacrum . . . The failed practice caused . . . actual harm for Resident #9 who developed a stage II pressure ulcer on the left knee, a stage III on the right knee and deterioration in other pressure ulcers . . . Page 14.
Inspection on 6/17/08 (12 pages) 1. ACCIDENTS AND SUPERVISION: . . .The facility failed to ensure adequate supervision was provided to prevent resident elopement [escape] from facility . . . The police’s investigative information dated 6/15/08 documented: “On 6/15/08 at approximately 8:50 p.m., [Local Citizen] reported to the Sheriff’s office dispatch that an elderly woman was walking on [Street approximately .6 mile from nursing home] and fell and appeared to be lost and confused . . . Upon my arrival, I saw [Local Citizen] holding upright in the sitting position a confused and somewhat dazed Resident #5 who had abrasions on her nose and right side cheek area from where she had fell on the asphalt . . . [Ambulance Service] was dispatched to the scene to check Resident’s condition and then transported her back to the [Nursing Home.”] The emergency room physician documented, “6/18/08 . . . noted to have facial and right knee abrasions with some mild swelling of right hand.” The radiology report dated 6/15/08. . . “Mildly comminuted, mildly displaced fractures through the proximal half of the right 5th phalanx.” Pages 1-5. 2. PROFICIENCY OF NURSES AIDES: . . . the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents’ needs as evidenced by leaving the side rails down while obtaining incontinent care supplies for Resident #1 . . . CNA stepped away from bed to closet and left side rail down. This nurse heard R hit the floor. The radiology reports dated 5/30/08: . . .“Fracture of the left femoral neck, Osteopenia” and “Left 7th rib fracture.” Pages 8-10.
Inspection on 12/14/07 (52 pages) 1. PRESSURE SORES: . . the facility failed to ensure all areas of the perineum were cleansed of urine and bowel movement (BM) to prevent the potential development of pressure sores. . . for Resident #8. . . Page 18.
2. ACCIDENTS AND SUPERVISION: . . .The facility failed to ensure. . . falls were investigated… Resident #9 sustained falls on 8/12/07, 8/14/07, 9/21/07, 9/22/07, 9/25/07, 10/22/07, 10/23/07 and 11/21/07. There was no documentation of investigations related to the falls. . . Pages 21-22.
Inspection on 9/28/07 (19 pages) 1. QUALITY OF CARE: . . . the facility failed to ensure the provision of oxygen therapy to prevent respiratory distress. . . LPN #1:.. At 7:30 p.m. picked up her hand to check her pulse noticed her fingers were blue. . . Resident had nasal cannula in nose. Looked to see if hooked to wall unit, was not. Check O2 (oxygen) tank behind her gerichair . . . The tank was on empty. Unhooked the tubing from tank, hooked to wall unit. Checked pulse ox was 68%. Left resident’s room at 8:10 p.m. After checking pulse ox again still 68%. . . Went in checked vitals again at 8:40 p.m. Pulse ox 76%, respirations 36 and pulse 134 while on 2L [liters] O2 via nasal cannula. . . She [LPN 3] took the updraft med, went into resident’s room. She came back said it didn’t work. . . The hospice nurse called with some doctor orders for Lortab 5/500 ii via rectum and Diazepam 5 mg IM injection. I called [Advanced Practice Nurse] verified these orders. She told me to give her the Diazepam to help c her heart rate but to wait on the Lortab to see if the Diazepam helped. 10:30 p.m. gave the Diazepam. . . Resident’s breathing became one breath, wait 1 minute then breathe. Called other nurse in listened to heart still beating 100 beats per minute. Resident closed eyes then stopped breathing at 11:10 p.m. Listen to heart beat heard no sound. . . Called coroner 11:35. . . Called DON [Director of Nursing] at 10:00 p.m. to see if I needed to chart in the chart about the O2 tank being empty she said no. . . Pages 9 & 11-13.
