Arizona State Veteran Home-Phx

Inspectors wroteBased on clinical record review, State Agency (SA) complaint/incident tracking system, resident and staff interviews, and policy review, the facility failed to implement written policies and procedures to prevent, report, and investigate an allegation of sexual abuse for one of three sampled residents (#67). The census was 95. The deficient practice could result in corrective actions not being taken and residents being further abused.

Inspectors wroteBased on clinical record review, State Agency (SA) complaint/incident tracking system, resident and staff interviews, and policy review, the facility failed to report an allegation of sexual abuse within the required timeframe for one of three sampled residents (#67). The census was 95. The deficient practice could result in corrective actions not being taken and residents being further abused.

Inspectors wroteBased on clinical record review, State Agency (SA) complaint/incident tracking system, resident and staff interviews, and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse for one of three sampled residents (#67). The census was 95. The deficient practice could result in corrective actions not being taken and residents being further abused.

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision to prevent elopement for one resident (#1) out of 3 sampled residents. The deficient practice could result in avoidable accidents.

Inspectors wroteBased on interviews, clinical record review, review of facility documentation, and review of facility policy and procedure, the facility failed to protect the rights of one (#67) of five sampled residents to be free from abuse by another resident (#61). The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on facility documentation, staff interviews, and policy review, the facility failed to ensure that the required staffing information and Certification and Survey Provider Enhanced Reporting (CASPER) Payroll-Based Journal (PBJ) data was submitted to CMS (Centers for Medicare & Medicaid Services) for one quarter. The deficient practice could result in residents receiving inadequate care due to a potential lack of staffing.

Inspectors wroteBased on documentation, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that the medical record, including recorded weights, was complete and accurate for two residents (#59). The deficient practice could lead to interdisciplinary team members not being aware of the resident's status and could lead to a gap in care.

Inspectors wroteBased on facility documentation, staff interviews, and policy review, the facility failed to ensure one resident's (#32) Preadmission Screening and Resident Review (PASARR) was completed accurately and was referred to state designated authorities for evaluation and determination. The deficient practice could result in residents not receiving specialized services needed.

Inspectors wroteBased on clinical record reviews, interviews, and facility policy, the facility failed to ensure that pharmacy recommendations for one resident (#14) were reviewed and addressed by the attending physician. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was adhered to following an incident involving an injury of unknown origin for one of three sampled residents (#3). The deficient practice could result in abuse policies not being followed, which could result in residents being harmed.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving a reported injury of unknown origin was thoroughly investigated for one of three sampled residents (#3). The deficient practice could result in injuries of unknown origin occurring without being appropriately investigated or identified in order to implement measures to protect residents.

Inspectors wroteBased on clinical record reviews, staff, resident and family interviews, and policies and procedures, the facility failed to ensure that allegations of abuse, neglect, and/or misappropriation of resident property were thoroughly investigated for residents (#3, #10, #11, #20, #30, #54 #63, #129, #146, #98, #14). The deficient practice could result in violations towards residents without being identified or without appropriate steps being taken to protect residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure resident #49 was free from elopement. The deficient practice could result in further incidents of elopement or physical injury.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide adequate supervision which resulted in the elopement of one resident (#22). The deficient practice could result in residents being physically and/or psychosocially harmed.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#79) was free from a significant medication error. The deficient practice resulted in the resident experiencing a Fentanyl overdose, requiring treatment at the hospital's Intensive Care Unit (ICU).

Inspectors wroteBased on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to ensure residents (#3 and #4) were free from abuse. The deficient practice could lead to further resident to resident abuse.

Inspectors wroteBased on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure the care plan was implemented related for fall prevention for one resident's (#2). The deficient practice could result in residents sustaining falls with injuries that may be preventable.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure an order for blood pressure medication was administered within the prescribed parameters for Resident # 7. The deficient practice could result in undesirable medication-induced harm.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate supervision was provided to prevent resident (#55) to resident (#12) abuse. The deficient practice could result in residents harming each other physically and emotionally.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedure, the facility failed to ensure skin pathologies and/or injuries for three residents (#9, #14, #25) were documented accurately. The deficient practice may result in suboptimal care to the residents due to pertinent clinical information being unavailable.

Inspectors wroteBased on record review, interviews, and review of facility policies and procedure, the facility failed to develop a discharge plan that meet the needs and goals of one of 3 sampled residents (Resident #8). The deficient practice could result in complicate the resident's recovery as well as the likelihood of regression in physical capability of the resident.

Inspectors wroteBased on observations, clinical record review, staff and resident interviews and review of facility policy, the facility failed to ensure adequate supervision was provided to prevent one resident (#84) from committing suicide. The deficient practice resulted in injury and hospitalization of the resident; and, increased risk of death by suicide.

Inspectors wroteBased on clinical record review, staff interviews and review of facility documentation, policy and procedure, the facility failed to ensure one resident (#7) was treated with dignity and respect by another resident (#25). The deficient practice could impact residents' emotional and psychological wellbeing.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for an allegation of sexual abuse for one resident (#12) was completed. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken.

Inspectors wroteBased on clinical documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#35) was free to exercise his rights regarding independent travel. The deficient practice could result in the resident not being able to exercise his rights without interference.

Inspectors wroteBased on clinical documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that three residents (#35, #42 and #55) was free to exercise their rights regarding independent travel. The deficient practice could result in the resident not being able to exercise his rights without interference and psychosocial harm. Findings Include: 1) Regarding Resident #35: Resident #35 was admitted to the facility on [DATE] with diagnosis of functional quadriplegia. The annual minimum data set (MDS) dated [DATE], included a brief interview for mental status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS also indicated that the resident has mild depression and trouble falling or staying asleep or sleeping too much. The MDS also included that the resident did not exhibit any behaviors. [...]

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure one resident (#4) was transferred safely using a Hoyer or similar lift in a manner consistent with professional standards. This deficient practice could result in accidental injuries related to Hoyer transfers.

Inspectors wroteBased on clinical record review, staff and resident interviews, review of facility policy, and the rules of the State Board of Nursing, the facility failed to ensure appropriate care and services related to indwelling catheter care was provided to two residents (#20 and #1). The deficient practice could result in residents not receiving necessary treatment and infection or the catheter having to be replaced sooner.

Inspectors wroteBased on observation, staff interviews, and policy and procedures, the facility failed to ensure one medication cart was locked, when left unattended. The deficient practice could result in residents, staff, and visitors having access to medications.

Inspectors wroteBased on observation, staff interviews, and facility documentation and policy review, the facility failed to ensure proper hand hygiene was implemented during suprapubic catheter care and flushes. The sample size was one. The deficient practice could result in infection.

Inspectors wroteBased on documentation, staff interviews, and facility policy and procedures, the facility failed to notify resident (#5) in writing regarding the reason for transfer to the hospital on two different dates and did not notify the office of the ombudsman.

Inspectors wroteBased on observation, staff interviews, and review of the facilities policy the facility failed to secure hazardous chemicals. The deficient practice could result in an increased risk of harm to residents. The census was 82. Observations were made on 07/19/2023 at 12:00 PM and 07/20/2023 at 11:36 AM of the kitchen area. The door to the kitchen supply room was propped open and a silver metal cabinet was observed. The door to the cabinet was open. The cabinet contained approximately 15 bottles that appeared to be cleaning products. The supply room was adjacent to areas containing cooking utensils, cups and trays. A list of the chemicals in the unlocked, open cabinet was provided. The list included; Ecotemp ultra Klene- Listed as Danger, causes severe skin burns and eye damage. Greasestrip Plus- Listed as Danger, causes severe skin burns and eye damage. [...]

Inspectors wroteBased on clinical records, staff interviews, resident interview, review of facility documents, policy and procedure, and observation of current practice, the facility failed to ensure one resident (#15 )was free from abuse. The deficient paractice could allow residents to be abused.

Inspectors wroteBased on documentation, staff interviews, and facility policy and procedures, the facility failed to give resident (#5) a bed-hold policy when transferred to the hospital on two different dates.

Inspectors wroteBased on observations, staff interviews, facility documentation, and policy reviews, the facility failed to ensure staff members wore hair restraints, food items were labeled and dated, the dishwasher sanitation was monitored, kitchenware was clean and dry, and that a fan was clean. The deficient practice could increase the risk of foodborne illness.

Inspectors wroteBased on staff interviews and facility documents, the facility failed to develop and implement their policy to ensure that contracted staff were vaccinated for COVID-19. The deficient practice may result in other staff not being vaccinated for COVID-19.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#42) and/or their representative were informed of the risks and benefits of a psychotropic medication prior to receiving the medication. The sample size was 6. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychoactive medications.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident's (#42) Preadmission Screening and Resident Review (PASARR) was updated after 30 days. The sample size was one resident. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation, and policy and procedures, the facility failed to provide evidence that mouth care was consistently provided to one resident (#54). The sample size was 2. The deficient practice could result in residents needing assistance not being provided oral care.

Inspectors wroteBased on observation, resident and staff interviews, and policy review, the facility failed to ensure a broken piece of kitchen equipment did not contaminate the food of one resident (#31). The deficient practice could put residents at risk of injury from non-food items in their food.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure a pharmacist recommendation was reviewed and acted upon for one resident (#30). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure a PRN (as needed) psychotropic medication had a stop date within the required timeframe for one resident (#13). The sample was five residents. The deficient practice could result in residents receiving medication that is not necessary.