Community Hospital of San Bernardino D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to implement a fall care plan intervention for one of four sampled residents (Resident 1). This failure resulted in Resident 1 falling off the bed, placing his safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was safely reconnected to the ventilator (a machine that supports or controls a person's breathing when they cannot breathe adequately on their own) following a shower. This failure resulted in an avoidable interruption in Resident 1's life supporting respiratory assistance and requiring a code blue response (an emergency code indicating a patient needs immediate medical attention), which had the potential to cause brain damage from lack of oxygen, and lead up to death. Resident 1 was subsequently transferred to Intensive Care Unit (ICU) for close observation and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of accidents for one of three residents (Resident 1) when Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) did not ensure the attachment holding the bar and scale of the Hoyer lift (a mechanical device used to transfer people from one surface to another) was properly secure prior to Resident 1's transfer. This failure resulted in the attachment holding the bar and scale of the Hoyer lift became disconnected which caused Resident 1 falling from the Hoyer lift, sustaining a head laceration (cut), and requiring suture and closed observation in the Intensive Care Unit (ICU).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program for 14 of 85 sampled residents (Resident 16, 18, 22, 24, 33, 41, 43, 52, 63, 68, 77, 82 and 83) when: 1. For one resident (Resident 41), there was no date or staff initial on Resident 41's gastro enteral tube (G tube- a feeding tube inserted through abdomen into the stomach to provide nutrition, fluids, and medication directly to the digestive system) and water flush bag (a bag with water administered to residents through G tube). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented appropriate interventions and oversight of restraints for two of eight sampled residents (Resident 38 and Resident 45) when: 1. Resident 38's mitten restraint (soft hand cover used to prevent a person from scratching or removing medical devices) was not properly worn or secured to Resident 38's right hand. 2. Resident 45's restraint was not reassessed monthly as required by the facility's policy and procedures (P&P) for Restraint, Physical Guidelines for Use and Assessment. These failures had the potential to result in unsafe restraint use, decreased resident safety and violation of residents' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary treatments and services to promote wound healing and prevent pressure ulcer (PU- a sore that develops on the skin when there is too much pressure on one area for a long time) development for two of 12 sampled residents (Resident 7 and Resident 37) when: 1. For two residents (Resident 7 and Resident 37), who were at risk for PU development, the repositioning was not documented every two hours. 2. For Resident 37, low air mattress was programmed with the incorrect resident weight. These failures may have contributed to the development of pressure ulcers in Resident 7 and Resident 37, potentially exposing them to harm and resulting in prolonged hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 5) received necessary treatment and services to maintain, increase range of motion (ROM- moving the joints to keep them flexible and prevent stiffness) or prevent further decline when nursing staff did not perform ROM as ordered by physician and specified in the care plan (a guide for nurses to follow regarding the plan of care). This failure had the potential to result in decreased mobility and pain and increased the risk of further contractures (muscles and tendons have tightened and shortened).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety and security of medications when Licensed Vocational Nurse 5 (LVN 5) left 12 medications on a computer desk unattended, and unsecured in a resident's room. This failure had the potential to place all 87 residents living on the unit at risk of harm due to increased risk for medication diversion (when a medication is taken for use by someone other than whom it was prescribed.)

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide full visual privacy for two of 28 sampled residents (Resident 59 and Resident 70) when there was no curtain between Resident 59's and Resident 70's bed. This failure had the potential to compromise resident 59's and Resident 70's dignity and right to full visual privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for four (4) of seven (7) sampled residents (Resident 51, Resident 69, Resident 57, and Resident 85) when: 1. Resident 51, who was not on transmission-based precaution (methods that are used to help stop the spread of germs from person to another), was observed less than three (3) feet (unit of measurement) apart from Resident 69 who was on transmission-based precautions. 2. The visitor of Resident 85, who was on droplet isolation (an infection control practice uses to prevent the spread of infection that are transmitted through respiratory droplets), was not educated about the proper use of Personal Protective Equipment (PPE-such as mask, gown and gloves worn to minimize exposure to illnesses) and was seen walking out of the isolation room without taking off the PPE. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Centers for Disease Control and Prevention (CDC-a service organization that protects the public's health's) guideline was followed appropriately for two (2) of four sampled residents (Resident 57 and Resident 85) when the Infection Preventionist (IP) did not assess, monitor, and manage the transmission-based precaution (methods that are used to help stop the spread of germs from person to another) appropriately. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to all residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's right were followed for one of four sample residents (Resident 81), when Resident 81 was placed on a left soft wrist restraint (device to prevent excessive movement of a body part to which they are attached) without an Informed Consent. This failure resulted in Resident 81 and Resident 81's Representative not being fully informed about the care and treatment provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the enteral nutrition (liquid nutrition administered via feeding tube) was administered as ordered for one of 88 residents (Resident 60) when the feeding pump (a device used to deliver food to patient via feeding tube) was not stopped as ordered for Resident 60, causing Resident 60 to receive excessive feeding. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise the health of Resident 60.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure secure storage of medications for one of 15 medication carts (a mobile cart used by licensed nurses to store and transport medication to resident rooms) when Medication Cart #1 was left unlocked and unattended by a licensed nurse in North wing. This failure had the potential to cause unsafe access from unauthorized personnel to medications which could potentially cause harms and injuries from misuse of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Two Steamtable pans (3.5-gallon containers) Full of fried beans and two steamtable pans (3.5-gallon containers) full of fried rice were found uncovered and unlabeled inside the refrigerator. 2. Beans which were cooling down, were not included on a cooling down log (a log used to ensure food is cooled to an appropriate temperature within a specified timeframe to prevent spoilage of food). 3. An opened box of three (3) pounds of turkey patties was found inside a refrigerator with no open date. 4. An opened box of approximately two (2) pounds of bacon was found inside a refrigerator with no open date. 5. Three (3) fifteen (15) pound boxes of bacon were found open and undated inside a refrigerator. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four residents (Resident 27, 52, and 62) sampled for enteral nutrition (a form of nutrition delivered to the digestive system in the form of a liquid usually through a feeding tube) received nutritional services as was prescribed by their doctor when: 1. The facility did not ensure staff labeled enteral nutrition bottles (bottles which contain the enteral nutrition) and water flush bags (bags filled with water administered with enteral nutrition) in accordance with their policy and procedure for Residents 27, and 52. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to complete a restraint monitoring assessment for one of three sample residents (Resident 79). This failure had the potential to result in skin breakdown and physical harm to Resident 79.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 32) received assessment and monitoring of pressure ulcers when Resident 32 was found to have a Deep Tissue Injury (DTI - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying tissue from pressure and/or shear) on the right heel but the facility had no documentation of the DTI indicated in Resident 32's skin assessments. This failure had the potential for a delay in the identification and subsequent treatment for Resident 32's DTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary catheter (a flexible tube used to empty bladder and collect urine in a drainage bag) was changed according to the physician's order for one of two sampled residents (Resident 33). This failure had the potential to cause a urinary infection to Resident 33 whose health condition was already compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change an intravenous (IV-administered into the vein) tubing for one of three sampled residents (Resident 338). This failure had the potential to result in serious infections and complications for Resident 338.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment was maintained in safe operating condition when: 1. One of four refrigerators observed, had condensation (water) dripping from the top of the refrigerator. 2. One of one freezer had ice forming on the floor and on the freezer fans. These failures had the potential for spoilage and/or contamination of the food stored inside the refrigerator and freezer which can cause foodborne illnesses to a population of three out of three medically compromised residents who received food from the kitchen.