Complete Care at Harrington Court

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for suicidal ideation, the facility failed to ensure that when Resident #1 continued to experience pain after administration of scheduled analgesics, licensed nursing staff assessed the ongoing pain and implemented available interventions, including review of the Medication Administration Record (MAR) and timely administration of ordered PRN pain medication. As a result, Resident #1's pain remained unrelieved, contributing to the escalation of distress and self harm behaviors.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for behaviors, the facility failed to ensure controlled substances were obtained, stored, and administered according to policy and federal requirements. Specifically, staff borrowed a controlled substance from another resident's supply and failed to administer the controlled medication according to the physician's order. The findind include:Resident #1's diagnoses included nondisplaced oblique fracture of the shaft of the right femur, periprosthetic fracture around the internal prosthetic right hip joint, pain due to internal orthopedic prosthetic devices, major depressive disorder, bipolar disorder with mild depression, and anxiety disorder. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for behaviors, the facility failed to ensure targeted behavior monitoring was initiated for an anti-psychotic medication.

Inspectors wroteBased on clinical record review, interviews, and facility document review, the facility failed to ensure that medication orders were accurately transcribed and verified for one (1) of two (2) residents reviewed for medication administration (Resident #1), resulting in a significant medication error when Methotrexate, ordered to be administered one time per week, was incorrectly transcribed and administered daily for nine (9) consecutive days. The error was not detected through required reconciliation processes, including RN transcription, supervisory second check, APRN review, physician review, and pharmacy consultant review, despite active MAR dose warnings. [...]

Inspectors wroteBased on clinical record reviews, facility documentation/policies and interviews for one (1) of two (2) sampled residents (Resident #3), reviewed for a change in condition, the facility failed to notify the residents Conservator of Person (COP), in accordance with facility policy, over an 8 day period, when the facility requested the provider evaluate the resident on two (2) occasions, due to a change in condition.

Inspectors wroteBased on review of clinical records, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #3) reviewed for changes in condition, the facility failed to ensure the provision of necessary care and services to assess and address a change in condition when a provider-directed chest x-ray was not ordered and completed as indicated.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of two (2) sampled residents (Resident #1), reviewed for medication administration, the facility failed to ensure the pharmacy reported irregularities in medication orders for Methotrexate to the physician when the frequency ordered was inconsistent with accepted standards of practice. The facility transcribed the medication dose for Methotrexate to be administered two (2) times per day instead of one (1) time per week. The pharmacy filled the medication at a daily frequency and when the monthly medication review for new admissions was conducted, the pharmacist failed to identify the order as a medication irregularity.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of two (2) sampled residents (Resident #3), reviewed for a change in condition, the facility failed to maintain complete and accurate clinical records for Resident #3 in accordance with the facility Documentation Policy when they failed to document assessments related to Resident #3's change in condition.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for Activities of Daily Living (ADLs), the facility failed to review and revise the plan of care to include the resident's refusal of showers and implement alternative interventions.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was at risk for weight loss, the facility failed to ensure weekly weights were obtained per the physician's order and failed to ensure a re-weight was obtained at the time a significant weight loss was identified and not wait one (1) week.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who had targeted behaviors, the facility failed to ensure a comprehensive care plan was developed and interventions implemented to address the resident's behaviors which included the tendency to transfer him/herself without assistance.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policies, and interviews for 1 of 8 residents (Resident #35) reviewed for abuse, the facility failed to ensure a resident was treated in a dignified manner by nursing staff.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #9, 91 and 81) the facility failed to ensure the physician and resident representative were notified according to facility policy. For 1 of 5 residents (Resident #9) reviewed for medication administration, the facility failed to ensure the physician was notified when medications were not given per the physician order. For 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure the physician and resident representative were notified when a new pressure ulcer was identified. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to notify the physician and resident representative with episodes of hypo and hyperglycemia, and when a medication was not administered.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for residents 4 of 8 residents (Resident #42, 88, 92 and 99,) reviewed for allegations of abuse, the facility failed to ensure the residents were free from abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 3 of 8 residents (Resident #69, 99 and 269) reviewed for abuse and misappropriation, the facility failed to immediately report the allegations of abuse and misappropriation to the Administrator and the State Agency according to established timeframes.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 8 residents (Resident # 99) reviewed for abuse, the facility failed to take immediate steps to prevent further abuse from occurring while the investigation was in progress.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #38 and 65) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to ensure a PASARR rescreen was completed upon admission to the facility for a resident with a long-standing history of a serious mental health diagnosis and after a new mental health diagnosis was identified.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #77) reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the physician's orders.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 4 residents (Resident #39, 69, 81, 268) the facility failed to provide care according to professional standards, facility policy and physician's orders. For 1 of 2 residents, Resident #39) reviewed for falls, the facility failed to ensure the functionality of a remote cardiac transmission device. For 1 resident (Resident #69) the facility failed to administer medications according to the physician's orders. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to follow the physician's orders and complete RN assessments when the resident had multiple episodes of hyperglycemia and hypoglycemia that required additional treatment. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure appropriate care according to professional standards and facility policy when a new pressure ulcer was identified.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #22 and 65) reviewed for respiratory care, the facility failed to ensure the CPAP (continuous positive airway pressure) tubing, filter, and mask were changed in accordance with the manufacturer's recommendations.

Inspectors wroteBased on review of the clinical record, facility policies, and interviews for 1 of 5 residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure a medication for the treatment of a mental health diagnosis was administered per the physician's order.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #269) reviewed for unnecessary medications, the facility failed to conduct a gradual dose reduction of Risperidone upon admission when the clinical record failed to reflect a psychiatric diagnosis.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for two (2) of thirteen (13) residents (Resident #1 and Resident #10) reviewed for abuse, the facility failed to ensure the residents were free from abuse.

Inspectors wroteBased on review of clinical records, interviews, and review of facility policies for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident's treatment order was entered correctly to ensure timely initiation of the practitioner's directive.

Inspectors wroteBased on review of clinical records, interviews, and review of facility policies for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that a resident was not provided an allergen at meal time.

Inspectors wroteBased on clinical record reviews, review of facility policy, and interviews for one (1) of four (4) sampled residents (Resident #4) who were reviewed for a resident-to-resident physical altercation, the facility failed to ensure Resident #4 was free from physical abuse when Resident #4 was hit on the head.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for four (4) of nine (9) residents (Residents #1, 2, 3 and 4) reviewed for misappropriation, the facility failed to prevent the misappropriation of the residents' controlled narcotic medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of four (4) residents (Resident #1) reviewed for medication administration, the facility failed to follow physician's orders when administering a medication.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of four (4) residents (Resident #1) reviewed for medication misappropriation, the facility failed to ensure that as needed narcotics were documented as administered and evaluated for effectiveness in the clinical record.

Inspectors wroteBased on observations of the dietary tray line, and review of facility documentation and interview, the facility failed to provide food at an appetizing temperature and failed to indicate holding temperature of sweet potatoes.

Inspectors wroteBased on clinical record reviews and interviews for 1 of 1 sampled resident (Resident #391) reviewed for constipation/diarrhea, the facility failed to ensure a baseline care plan was completed to address the resident's constipation.

Inspectors wroteBased on clinical record reviews, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #50) reviewed for wound prevention and healing, the facility failed to follow the residents plan of care and the physician's orders to off load/float heels when the resident was identified with wounds on both heels and for one of three residents ( Resident # 5) at risk for pressure ulcer development, the facility failed to ensure the resident's air mattress was set according to the plan of care.

Inspectors wroteBased on clinical record reviews, facility policy and interview for 1 of 2 sampled residents (Resident #389) reviewed for hydration, the facility failed to maintain fluid intake per physician's order.

Inspectors wroteBased on review of the facility Payroll Based Journal (PBJ) records, interview, and review of facility policy for 4 out of 4 quarters reviewed, the facility failed to maintain weekend staffing at a level that was above excessively low, and for 2 of 4 quarters, failed to ensure the facility did not receive a 1 star rating for staffing.

Inspectors wroteBased on observations, clinical record review, staff interviews, policy review, and facility documentation, for 1 of 1 sampled resident (Resident #65), reviewed for respiratory care, and for 1 of 1 sampled resident, (Resident #439), reviewed for infection prevention, the facility failed to ensure that infection prevention practices were followed and for one of six units, the facility failed to ensure bed pans were properly labeled and stored according to facility policy.

Inspectors wroteBased on observations of the kitchen, facility documentation and interview, the facility failed to properly store food in sanitary conditions.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure nurse and nurse aide staffing information posted was accurate and up to date.

Inspectors wroteBased on review of the clinical record, facility policy and interview for one of five residents (Resident #30) reviewed for unnecessary medications, the facility failed to monitor recommended resident behaviors.

Inspectors wroteBased on review of the clinical record, review of facility policy and interviews for one of two sampled residents (Resident #30) reviewed for dental, the facility failed to ensure dental services were provided to replace the resident's lost dentures.

Inspectors wroteBased on review of facility documentation, facility employee job description and interview, the facility failed to designate a specific individual (with the required training and qualification) to oversee the facility infection control program.

Inspectors wroteBased on review of the clinical record, review of facility policy and interviews for one of twenty-four residents (Resident #26), reviewed for Advance Directives, the facility failed to ensure physician's order was in place that honored the resident's health care instructions for Advanced Directives.

Inspectors wroteBased on review of the clinical record, review of facility policy and interviews for the only sampled resident (Resident # 56) reviewed for notification of change, the facility failed to notify the conservator of an abnormal diagnostic result.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for one of three residents (Resident #67) reviewed for choices and for the only sampled resident (Resident #70) reviewed for specialized treatment, the facility failed to ensure a comprehensive person centered care plan was developed for the residents.

Inspectors wroteBased on review of the clinical record, facility policy, and staff interview for one of five residents in the survey sample reviewed for unnecessary medications, (Resident #17), the facility failed to revise the resident care plan related to antipsychotic medication use.

Inspectors wroteBased on review of the clinical record and interviews for one of three sampled residents (Resident #67) reviewed for choices, the facility failed to ensure a medication was available and administered per the physician's order.