Benedictine Living Center of Garrison

Inspectors wroteBased on observation, record review, review of the facility competency guide, review of professional reference, and staff interview, the facility failed to follow professional standards for 1 of 2 sampled residents (Resident #3) reviewed for blood sugars levels, and 1 of 1 supplemental resident (Resident #27) observed during administration of an oral inhaler. Failure to notify the provider of out-of-range blood sugars levels may lead to inaccurate insulin dose administration and/or adverse health conditions, and failure to prompt a resident to rinse his/her mouth with water after administration of an inhaler has the potential to cause side effects in the oral cavity related to the medication.

Inspectors wroteBased on observation, review of the facility competency guide, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 2 sampled residents (Resident #7) observed during a dressing change. Failure to practice infection control standards related to dressing changes and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell from a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to honor the resident/resident representative's wishes for code status resulted in unwanted treatment for Resident #4. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on record review, review of facility policy, and staff interviews the facility failed to ensure residents remained free from resident-to-resident abuse for 2 of 3 sampled residents (Residents #24 and #51) and 4 supplemental residents (Resident #3, #11, #31, and #36) who received or displayed physical and/or verbal abuse. Failure to identify physical altercations between residents as physical abuse placed residents at risk for possible emotional distress and/or physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incidents.

Inspectors wroteBased on record review, review of facility policy, and staff interview the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 2 of 3 sampled residents (Resident #24 and #51) and 1 supplemental resident (Resident #31). Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse.

Inspectors wroteBased on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 3 of 4 residents (Resident #6, #23, and #40) observed during administration of rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 4 residents (Resident #20 and Resident #40) observed during medication administration. Four medication errors occurred during staff administration of 32 medications, resulting in a 12.5 percent error rate. Failure to properly prepare medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 13 sampled residents (Resident #11, #14, #21, #26, and #27) and one supplemental resident (Resident #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 7 sampled residents (Resident #14 and Resident #27) and 5 supplemental residents (#1, #12, #18, #39, and # 47) observed during personal cares or transfers. Failure to practice infection control standards related to hand hygiene and cleaning of mechanical lifts has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, staff and resident interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 1 supplemental resident (Resident #2) with medications observed in the room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident.

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 3 sampled residents (Resident #13) with an indwelling catheter. Failure to follow physician's orders for residents with indwelling catheters may result in delayed treatment, pain and/or worsening of resident's condition.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 4 sampled residents (Resident #13) observed during a pivot transfer. Failure to provide adequate assistance and use the assistive devices properly during transfers placed the residents at risk for accidents, falls, or injuries.

Inspectors wroteBased on facility policy, record review, and staff interview, the facility failed to ensure a physician's response to changes in resident's weight for 3 of 3 sampled residents (Resident #23, #44, and #45) with significant weight loss. Failure to ensure the physician responded in a timely manner may result in a delay of treatment and further weight loss for residents.