Columbia Post Acute

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain physician ordered settings for Continuous Positive Airway Pressure (CPAP) machine (non-invasive mechanical ventilation device) for three residents (Residents #66, #22 and #30) of three sampled residents who required the use of a CPAP. The facility census was 62.1. Review of the facility's policy titled CPAP/Bi-level positive airway pressure (BiPAP), non-invasive mechanical ventilation machine, Support, dated March 2015, showed staff to document the following in the resident's medical record: -Time CPAP started and duration; -Mode and settings for CPAP; -How resident tolerates CPAP therapy; -Oxygen saturation during CPAP therapy. Review of the facility's policy titled Medication and Treatment Orders, dated July 2016, showed orders for medications must include: [...]

Inspectors wroteBased on record review and interview, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when facility staff administered an incorrect dosage of Morphine to the resident. The census was 67. 1. Review of the facility's Administering Medications policy, dated 04/2019, showed staff are directed as follows: -Medications are administered in accordance with prescribed orders; -Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and or the need for additional staff training; -The individual who administers the medication should check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before medication is administered. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for seven residents (Resident's #5, #13, #14, #27, #29, #35, and #40) out of 25 sampled. The census was 66. 1. Review of the facility's policy Care Plans, Comprehensive Person Centered, dated March 2022, showed care plans are developed within seven days of completion of the required MDS (Minimum Data Set), a federally mandated assessment tool (Admission. Annual, or Significant Change of Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents is ongoing and care plans are revised as information about the resident and the residents' conditions change. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to conduct regular entrapment assessments for seven (Resident #5, #13, #14, #17, #29, #35 and #40) out of seven sampled residents who used bed rails . The facility census was 66. 1. Review of the facility's Bed Safety and Bed Rails policy, dated August 2022, showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. Regardless of mattress, type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are with the safety dimensions established by the Food and Drug Administration (FDA). Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including entrapment risks. [...]

Inspectors wroteBased on interview and record review, facility staff failed to accurately transcribe one resident's (Resident #18) eye drop medication orders from the hospital which resulted in the resident not receiving necessary medications during their stay at the facility. The facility census was 66. 1. Review of the facility's policy titled Reconciliation of Medications on Admission, revised July 2017, showed medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a medication administration error rate of less than 5% out of 38 opportunities observed, two errors occurred resulting in a 5.26%, which effected one residents (Resident #35) out of 21 sampled residents. The facility census was 66. 1. Review of the facility's policy titled Administering Medications, dated April 2019, showed the Director of Nursing (DON) supervises and directs all personnel who administer medications. Medications are administered in accordance with prescribe orders. The individual administering medications verifies the right resident, right medication, right dosage, right time, and right route before giving the medication. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the activities program was directed by a qualified professional. The facility census was 66. 1. Review of facility records showed they did not have a policy in regard to qualifications for the Activity Director (AD) position. Review of the facility's Activity Director Job Description, undated, showed the primary purpose of the AD position is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current federal, state, local and corporate standards, regulations, and guidelines to assure than an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental, and psychosocial needs of each resident. Keep current of federal and state regulations, as well as professional standards. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to wear hairnets and beard guards, to ensure the ice machine drained through an air gap, to maintain the kitchen in a clean and sanitary manner, to store food in a manner to prevent outdated usage and cross contamination, and to perform handwashing when appropriate. These failures had the potential to affect all residents. The census was 64. 1. Review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, showed hairnets and beard guards are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Observation on 8/8/23 at 11:15 A.M., showed dietary aide (DA) R prepared residents' lunch plates for service. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain a professional standard of care when staff did not follow manufacturer's guidelines to administer insulin using an insulin pen for one resident (Resident #22), failed to obtain specific orders for one resident's (Resident #1) tracheostomy (opening in neck to place a tube to allow air into the lungs) and to have a suction machine at the bedside side, failed to obtain an order and plan care for the use of a catheter (a tube to drain the bladder) for two residents (Resident #308 and #323), failed to discontinue an order for catheter use for one resident (Resident #26) who no longer used a catheter, failed to obtain an order and plan care for the use of a Continuous Positive Airway Pressure (CPAP - pressure to used to help keep airway open) machine for one resident (Resident #15), failed to obtain an order [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to assist five out of 16 sampled dependent residents (Resident #5, #12, #21, #33, and #313) with grooming and bathing. The facility census was 64. 1. Review of the facility's Activities of Daily Living (ADLs) policy, dated March 2018, showed staff were directed as follows: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); - Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility's Shaving the Resident policy, dated February 2018 showed staff are directed to review the resident's care plan for any special needs of the resident. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to secure and store medications in a manner to prevent access to residents, visitors and staff. Additionally, facility staff failed to provide safe mechanical lift transfers for two residents (Residents #5 and #7) in a manner to prevent accidents. The facility census was 64. 1. Review of the facility's Storage of Medications policy, dated November 2020, showed: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications; -Compartments (including, but not limited to, drawers, cabinets, rooms refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to conduct or complete entrapment assessments and measurements to identify areas of possible entrapment on admission and quarterly for five of eight sampled residents (Resident #1, #26, #36, #37, and #308) who used bed rails. The facility census was 64. 1. Review of the facility's policy titled, Bed Safety and Bed Rails, date revised August 2022, showed staff are directed to do the following: -Bed rails (also referred to as side rails, safety rails, grab assist bars in this policy) are adjustable metal or rigid plastic bars that attach to the bed; -Bed rails are available in a variety of types, shapes, and sizes ranging from one-half, one-quarter, or one-eighth lengths; -The resident's sleeping environment is evaluated by the interdisciplinary team; [...]