Claiborne Rehabilitation

Inspectors wroteBased on record reviews and interviews, the facility failed to provide written notice to residents and/or their RP (Responsible Party) of the bed hold agreement at time of transfer and update the emergency transfer log (Notice of Discharge to the ombudsman) for 1 (#7) of 2 (#7 & #44) residents reviewed for hospitalizations.

Inspectors wroteBased on record review, observation, and an interview the facility failed to ensure services provided met professional standards of quality for 1 (#5) of 1 resident with a peg (percutaneous endoscopic gastrostomy) tube observed during medication administration. Review of facility's Administering Medications through an Enteral Tube policy (revision date 01/15/2025) revealed in part:Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Steps in Procedure:6. Verify placement of feeding tube:a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide current pharmaceutical services to meet the needs of each resident as evidenced by having expired medications and supplies readily available for resident use on 1 (cart A) of 1 medication cart and in 1 (medication storage room A) of 2 medication storage rooms observed.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents' medical records reflected the resident's advance directive wishes for 1 (#6) of 19 (#1, #6, #7, #9, #10, #17, #18, #24, #27, #28, #29, #32, #36, #37, #38, #39, #90, #92, #240) total sampled residents. The facility failed to ensure the profile page, physician's orders, medication administration records, comprehensive care plan and LaPost (Louisiana Physician Orders for Scope of Treatment) were consistent with the resident's wishes for advance directives.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure the correct use and the maintenance of bed rails by ensuring residents were care planned for the use of bed rails, assessed for the risk of entrapment from bed rails, and a written order was obtained from the physician for bed rails prior to installation for 4 (#7, #27, #90, #240) out of 5 (#6, #7, #27, #90, #240) residents reviewed for accidents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place. This deficient practice had the potential to affect any of the facilities 46 residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a resident has a right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 (#37) resident out of 2 (#37 and #90) residents investigated for physical restraints. The facility failed to ensure 1.) A written order was in place 2.) A consent for the use of a lap tray was obtained, 3.) A specific reason for the restraint and 4.) An assessment was completed for the use of a lap tray for Resident #37.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure 1 (#1) of 2 (#1, #2) residents whom was assessed at high risk for elopement, was adequately supervised to prevent him from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 12/18/2023 at approximately 5:30 p.m. when Resident #1 (a severely cognitively impaired resident identified as an elopement risk), was unsupervised and eloped from the facility. Resident #1 was found lying on the ground of a creek bank approximately ¼ of a mile from the facility on 12/18/2023 at 8:06 p.m. by the Sherriff's Department. Resident #1 was taken to the local emergency department for evaluation. Review of the local emergency department notes dated 12/18/2023 at 9:35 p.m. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure 1 (#1) of 2 (#1, #2) residents (whom were at high risk for elopement and resided in the secured unit), was adequately supervised to prevent Resident #1 from eloping. This deficient practice resulted in an Immediate Jeopardy situation on 12/18/2023 at approximately 5:30 p.m. when Resident #1 (a severely cognitively impaired resident identified as an elopement risk), was unsupervised and eloped from the facility. Resident #1 was found lying on the ground of a creek bank approximately ¼ of a mile from the facility on 12/18/2023 at 8:06 p.m. by the Sherriff's Department. Resident #1 was taken to the local emergency department for evaluation. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to ensure a resident's elopement from the facility was reported to the State Survey Agency in accordance with State law no later than 24 hours for 1 (#1) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review and interview the provider failed to ensure a resident's code status was correct for 1(Resident #10) of 1(Resident #10) reviewed for advanced directives/code status.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (#7) of 2 (#7, #44) sampled residents reviewed for skin conditions and 1 (#12) of 1 (#12) sampled resident reviewed for pressure ulcers. The facility failed to ensure: 1. Resident #7's wound care was conducted as ordered. 2. Resident #12's wound care and Calmoseptine ointment to perineal area was completed daily.

Inspectors wroteBased on observation and interviews, the facility failed to maintain an effective infection control and prevention program designed to provide a safe and sanitary environment by failing to ensure staff performed hand hygiene while serving dietary trays and beverages. The deficient practice had the potential to affect 46 residents according to the Resident Census and Conditions of Residents Report.

Inspectors wroteBased on observations and interviews the facility failed to ensure all patient care equipment was maintained in safe operating condition by failing to repair equipment for 3 (#6, #22, #36) residents out of 21 residents with mobility in a chair all or most of the time according to the Resident Census and Conditions of Residents Report. The facility failed to maintain the following patient care equipment: a wheelchair arm rest (#6); a wheelchair arm tray (#22); and brakes on a gerichair (#36).

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Discharge MDS (Minimum Data Set) Assessment and a readmission MDS Assessment was completed after a resident was discharged from and readmitted to the facility. The deficient practice affected 1 (#36) of 2 (#36, #102) residents investigated for hospitalizations.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) Assessment was completed within 14 days of a resident sustaining a right hip fracture for 1 (#45) of 2 (#7, #45) sampled residents reviewed for falls.