Bethany Home Association

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an in-service training program for Certified Nurse Aide (CNA) M, specific to the needs of the resident population.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure Resident (R) 1, who was severely cognitively impaired and on hospice, remained free from staff to resident abuse.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure staff reported allegations of staff to resident abuse immediately to the administrator as required.

Inspectors wroteBased on record review and interviews, the facility failed to ensure agency staff received the required infection control training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate infection control practices related to urinary catheter (tube inserted into the bladder to drain urine) care, hand hygiene, and the sanitary storage of respiratory equipment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)47's call light was within his reach to enable him to call for staff assistance. Findings Included:- R47's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure Resident (R)66 had an appropriate indication, or a documented physician rationale, which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorders characterized by a gross impairment in reality testing).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an environment free of potential accident hazards for Resident (R) 14 when staff failed to use two staff during a Hoyer (full body mechanical lift) as required.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to address a significant weight loss for Resident (R) 2, which had the potential for physical complications related to nutritional deficits.

Inspectors wroteThe facility had a census of 75 residents. The sample included three residents, with one reviewed for a change of condition. Based on observation, record review, and interview, the facility failed to notify Resident (R) 1's representative when R1 had a change in condition. This deficient practice placed R1 at risk for a lack of required decision from her representative for treatment.

Inspectors wroteThe facility had a census of 75 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to notify the physician regarding issues with red drainage from a urinary catheter (a tube inserted into the bladder to drain urine) and the lack of urine output for the night shift for one resident, Resident (R) 2. This placed the resident at risk for physical decline and urinary tract infections (UTI- infection in any part of the urinary system).

Inspectors wroteThe facility identified a census of 73 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. The facility further failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing high-contact care to Resident (R) 36. This placed the residents in the facility at risk for infectious disease. Findings Included: [...]

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents with four reviewed for urinary catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, interview, and record review the facility failed to provide adequate catheter care per standards of practice for Resident (R)36's urinary catheter. This deficient practice placed R36 at risk for urinary tract infections (UTI- an infection in any part of the urinary system) and other catheter-related complications.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 12 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization. This placed the resident at risk for unmet mental healthcare needs and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 70 residents. The sample included 18 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure an approved indication for use or the required physician documentation as well as ongoing monitoring for effectiveness and the ongoing necessity for the use of antipsychotic drugs (class of medications used to treat psychosis and other mental-emotional conditions) and psychotropic (alters mood or thought) drugs for Resident (R)121 and failed to ensure a stop date for as needed (PRN) lorazepam (antianxiety drug) for R41. This deficient practice placed R41 and R121 at risk for unnecessary antipsychotic and psychotropic drugs and related side effects.

Inspectors wroteThe facility identified a census of 60 residents. Based on record review and interview, the facility failed to ensure their Medical Director attended the Quality Assessment and Assurance (QAA) committee meetings at least quarterly. The deficient practice placed the residents of the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety when staff used contaminated gloves to transfer food items from one container to another while preparing the three residents mechanical soft diets. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist (CP) notified the physician and director of nursing services of the requirement for a stop date or rationale for the continued use of an as needed (prn) psychotropic (altering mood or thought) drug, lorazepam (antianxiety drug) for Resident (R) 40. This deficient practice placed R40 at risk for unnecessary continuation of the prn lorazepam and its potential side effects.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date or a rationale for the continued use of an as needed (prn) psychotropic (altering mood or thought) drug, lorazepam (antianxiety drug) for Resident (R) 40. This deficient practice placed R40 at risk for unnecessary continuation of the prn lorazepam and its potential side effects.

Inspectors wroteThe facility had a census of 60 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing two residents' pureed diets. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for two of four days of the onsite survey.