Brian Center of Fincastle

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, facility staff failed to ensure a ventilator dependent resident was provided with such care consistent with professional standards of practice resulting in death of the resident for 1 of 4 residents in the survey sample (Resident #1). Resident #1 was admitted to the facility with diagnoses which included acute and chronic respiratory failure with hypoxia, respiratory ventilator dependence, tracheostomy status, cerebral palsy, epilepsy, and dysphagia. On the most recent Minimum Data Set assessment, the resident was assessed as comatose/persistent vegetative state. Clinical record review revealed: On 3/13/2024, Resident #1 was found unresponsive and without pulse or respirations. Death was pronounced at 9:05 PM. [...]

Inspectors wroteBased on staff interview, clinical record review, and during a medication pass and pour observation the facility staff failed to follow the providers order in regards to administering the medication Peridex for 1 of 3 residents observed during the medication pass and pour observation, Resident #44.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure 1 of 18 current residents, Resident #9 was free of accident hazards. Resident #9 did not have their provider ordered bilateral floor mats in place.

Inspectors wroteBased on interviews, clinical record reviews, facility document review, and during the course of a complaint investigation, the facility staff failed to ensure indwelling urinary catheter care orders were obtained and indwelling urinary catheter care was provided for two (2) of 20 sampled residents (Resident #15 and Resident #102).

Inspectors wroteBased on observations, interviews, clinical record review, and facility document review, the facility staff failed to ensure infection control isolation precautions signage was posted for two (2) resident rooms that housed residents requiring infection control precautions; one (1) of the rooms housed a newly admitted /readmitted resident that was not fully vaccinated for COVID-19. Resident #105's room did not have an isolation precaution sign posted outside their room. After the missing isolation precaution sign was discussed with facility staff, Resident #105 had an incorrect isolation precaution sign initially posted outside their room. Resident #2's room did not have an isolation precaution sign posted outside their room.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to implement infection control prevention and control processes related to the vaccination status of one of three sampled staff members (LPN #5), as part of the plan to decrease the risks of the development and transmission of COVID-19. For licensed practical nurse (LPN#5), the facility staff failed to ensure the nurse was fully vaccinated for COVID-19 resulting in the facility's staff vaccination rate being less than 100% (99.2%).

Inspectors wroteBased on staff interview, employee record review, and facility document review, the facility staff failed to implement their policy related to preventing abuse, neglect and exploitation in regards to new hires for 1 of 15 new hires, (RN) registered nurse #1.

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan as evidenced by failure to follow physician's orders for 1 of 15 residents, Resident # 35.

Inspectors wroteBased on staff interview and clinical record review facility staff failed to provided wound care as ordered by the physician for 1 of 15 residents, Resident #28. Facility staff members failed to ensure Resident #28's wound care was performed according to medical provider orders. Resident #28's minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/29/2020 had the resident assessed as usually able to make self understood and as usually able to understand others. Resident #28's Brief Interview for Mental Status (BIMS) summary score was documented as 12 out of 15. Resident #28 was documented as being dependent with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #28's diagnoses included, but were not limited to: anemia, heart disease, high blood pressure, lung disease, diabetes, and paraplegia. [...]

Inspectors wroteBased on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure tube feeding orders were correctly implemented for two (2) of 15 residents (Resident #17 and Resident #29).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to act upon a monthly drug regimen review for 1 of 15 residents in the survey sample, Resident #48.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents were free from unnecessary psychotropic medications for 1 of 15 residents, Resident #25.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) errors in 26 opportunities for a medication error rate of 7.69%. These medication errors affected Resident #16 and #19.

Inspectors wroteBased on observations, interviews, and the review of documents, it was determined facility staff members failed to perform hand hygiene when changing gloves during wound care for two (2) of 15 sampled residents (Resident #24 and Resident #32).

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure the dish machine was in proper working order.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to properly label and store drugs and biologicals for 2 of 19 and in 2 of 3 medications carts and in the medication storage rooms (Residents #7, and #14, Medication Cart #1, Medication Cart #2 and Medication Storage Room).

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a hazard free environment on 3 of 3 halls.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide privacy during wound care for 1 of 19 residents in the survey sample (Resident #37).

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide privacy during wound care for 1 of 19 residents in the survey sample (Resident #37).

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to provide proper treatment during a wound care observation for 2 of 19 residents in the survey sample (Resident #26 and Resident #37).

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 19 Residents, Resident #22.