Brown Health and Rehabilitation

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from sexual abuse by another resident by not reporting to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R85) reviewed for abuse and neglect. The deficient practice had the potential of future unreported abuse.

Inspectors wroteBased on observations, staff interviews and review of the facility's policy titled, Infection Prevention Plan, the facility failed to ensure proper infection control procedures were followed for four residents (R) (R5, R11, R1 and R78), creating cross-contamination. This failure had the potential to contribute to the transmission of infectious diseases among residents and staff.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy titled, Standard Patient Room Cleaning, the facility failed to ensure prevention of spread of infection by using foam protectors in disrepair over bed rails that created an uncleanable surface for four of four Residents (R) (R19, R22, R10, and R13) reviewed for side rail use. This deficient practice had the potential for the foam covers on the side rails to harbor bacteria and spread infection to the residents.

Inspectors wroteBased on interviews, record review, and review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating, the facility failed to complete a thorough investigation for two of two sampled Residents (R) (R48 and R82) reviewed for abuse. Specifically, there was no evidence the facility interviewed R48 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations.

Inspectors wroteBased on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete and electronically transmit a Discharge Minimum Data Set (MDS) assessment to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two of two residents (R) (R35 and R80) reviewed for discharge to home.

Inspectors wroteBased on interviews, record review, and review of facility's policy titled, Patient's Plan of Care, the facility failed to update a Care Plan for one Resident (R) (R31) when a pacemaker monitoring device was provided to the facility and failed to ensure one (R1) was invited to participate in the quarterly care plan meeting. These failures had the potential for R31 not to receive necessary care and services for a pacemaker monitoring device and R1 not to be involved in decisions affecting care in the facility. The sample size was 41 residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Using A Portable Lifting Machine, the facility failed to ensure a mechanical lift sling was inspected for damage and defects after laundering for one out of five residents (R) (R13) reviewed for falls. The deficient practice caused R13 to fall from a mechanical lift sling because of a broken strap while being transferred from his motorized wheelchair to the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were informed or educated about the remote cardiac monitor's purpose for one of one Resident (R) (R 31) with a pacemaker monitor. The deficient practice had the potential to place R31 at risk of not receiving necessary care and monitoring for cardiac instability.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled Skilled Inpatient Services - ADL Plan of care, the facility failed to follow the care plan for eight residents (R) (R#26, R#35, R#43, R#7, R#23, R#27) related to activities of daily living (ADL), R#19 related to falls, and R#24 related to elevated finger stick blood sugar levels. The sample size was 33.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Skilled Inpatient Services -ADL Plan of Care, the facility failed to provide activities of daily living (ADL) care for six residents (R) (R#26, R#35, R#43, R#23, R#27, R#7). The sample size was 33.

Inspectors wroteBased on observations, record review, interviews, and review of facility policies, the facility failed to implement an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced infection control standards during wound care for two residents (R) (R#43 and R#71) and by not storing respiratory supplies properly for one resident (R#18). The census was 75. 1. Review of the policy titled Skilled Nursing Services Wound Care revised 10/11/2022 revealed the intent is to provide guidelines for clean technique in providing wound care. Start with a clean surface and a clean tray, using approved cleanser and observing appropriate wet times. Cover the tray with an impervious barrier. Prepare the supplies on the tray with the barrier. Upon entering room, place tray on a clean surface. [...]

Inspectors wroteBased on observations, record review, policy review, interviews, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by two Licensed Practical Nurses (LPN), administered insulin to R#18, using another resident's insulin pen on two different occasions. The sample size was 33.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to follow Physician Orders for one resident (R) (R#24) related to sliding scale insulin order to notify the physician for blood sugars greater than 401. The sample size was 33. Findings Include: Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including congested heart failure (CHF), chronic obstruction pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, and restless leg syndrome. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Section N revealed resident received insulin injections seven days during the look back period. [...]

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to implement restorative nursing care for three residents (R) (R#35, R#43, R#70) as recommended post discharge from inpatient Rehabilitation Services. The sample size was 33 residents.

Inspectors wroteBased on observations, record reviews, interviews, and review of the facility policy titled Fall Management, the facility failed to assure the safety of one resident (R#19) with a history of falls, by not placing resident in bed when she was asleep and leaning forward in wheelchair. The sample size is 33.

Inspectors wroteBased on observations, resident and staff interviews, and review of facility polices, the facility failed to ensure respiratory care was provided in accordance with standards of nursing practice for two of 13 residents (R) receiving oxygen therapy. Specifically, the facility failed to change the oxygen nasal cannula for R#37 and failed to administer oxygen at prescribed flow rate for R#51.

Inspectors wroteBased on resident and staff interviews and review of facility policy titled Orientation, Training, and Competency, the facility failed to ensure staff was competent related to maintaining resident Bilevel Positive Airway Pressure (BiPAP) units used in the facility. The census was 75.