Edgecombe Health Center by Harborview

Inspectors wroteBased on record review and interviews with staff, the Physician and Nurse Practitioner (NP), the facility failed to ensure that Nurse Practitioner visits were comprehensive and included a review of the Medication Administration Records (MARs). On [DATE], an emergency room (ED) physician prescribed Lasix (furosemide) 20 milligrams (mg), (diuretic/water pill) daily for 3 days and Prednisone 20 mg, 3 tablets daily for 5 days for dyspnea (shortness of breath), Chronic Obstructive Pulmonary Disease exacerbation (long term lung conditions that cause irreversible damage to the airway), and fluid overload (retention of water and sodium). On [DATE], a nurse entered the Prednisone order into the electronic record but did not activate a 5-day stop date. As a result, the medication remained active and continued to be administered until [DATE]. [...]

Inspectors wroteBased on record review, and staff, Pharmacy Consultant, Pharmacy Quality Assurance Manager, and Physician interviews, the facility failed to have effective systems in place for accurate acquiring of medications and the pharmacy failed to have effective systems in place to prevent refilling a medication order 3 times after the stop date. On [DATE] Resident #162 was seen in the emergency department (ED) for shortness of breath, dyspnea, COPD exacerbation and fluid overload and returned to the facility just before midnight. The ED Physician prescribed Prednisone 20 mg (milligrams) 3 tablets (total of 60 mg daily) at breakfast for 5 days for diagnosis of dyspnea (shortness of breath or difficulty, uncomfortable breathing), chronic obstructive pulmonary disease exacerbation (long term lung diseases that cause inflammation and damage to airways, making it difficult to breathe). [...]

Inspectors wroteBased on record review, staff, Pharmacist and Physician interviews, the facility failed to ensure the Pharmacist provided monthly medication regimen reviews that included a comprehensive review of the resident's medical record, including the medication administration record to identify medication irregularities. The Pharmacist medication regimen review (MRR) dated [DATE] through [DATE] did not identify irregularities related to ongoing Prednisone (a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including allergies, autoimmune disorders, and respiratory diseases) 20 milligrams (mg) order (3 tablets by mouth with breakfast for 5 days starting [DATE]. [...]

Inspectors wroteBased on record review, and staff, Physician, Pharmacy Quality Assurance Manager interviews, the facility failed to have effective systems in place to prevent a significant medication error. On [DATE] Resident #162 was seen in the emergency department (ED) for shortness of breath, dyspnea, chronic obstructive pulmonary disease (COPD) exacerbation and fluid overload and returned to the facility just before midnight. The ED Physician prescribed Prednisone 20 mg (milligrams) 3 tablets (total of 60 mg daily) at breakfast for 5 days. Prednisone is a corticosteroid used to reduce inflammation and suppress an overactive immune system, treating a wide range of conditions including respiratory diseases. [...]

Inspectors wroteBased on record review and staff, Nurse Practitioner (NP) and Physician interviews, the facility failed to obtain daily weights as ordered by the physician. This was for 3 of 8 residents reviewed for the provision of care in accordance with professional standards of practice (Resident #17, Resident #35, and Resident #129).

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of nutritional approaches (Resident #79) and intravenous (into a vein) access (Resident #180). This was for 2 of 62 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations, record review, resident, Speech Therapist, and staff interviews, the facility failed to serve food in a form that met the resident's needs for 1 of 1 resident (Resident #14) reviewed. Resident #14 had been ordered food that was pureed texture and was observed to receive a soaked dinner roll.

Inspectors wrote4. Resident #139 was admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 was discharged to a short-term general hospital. A progress note written by the Social Worker on 1/22/25 at 2:44 PM stated Resident #139 was discharged from the facility at 12:45 PM and was transported home by his friend. During an interview with the MDS Coordinator on 3/12/25 at 1:15 PM, she stated the MDS should have been coded to home and her coding was an error. An interview with the Director of Nursing was held on 3/12/25 at 1:23 PM, at that time she stated the resident was discharged home. During an interview on 3/12/25 at 1:26 PM, the Administrator stated her expectation would have been the MDS information was coded accurately. 3. Resident #80 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review, resident responsible party (RP) and staff interviews, the facility failed to include documentation in the medical record that the facility staff had spoken with the responsible party (RP) or resident regarding advance directives (Resident #110). This was for 1 of 5 residents reviewed for advance directive.

Inspectors wroteBased on record review and staff and Responsible Party (RP) interviews, the facility failed to provide a Centers for Medicare and Medicaid (CMS) Form 10123-Notice of Medicare Non-Coverage (NOMNC) within the required time frame. This was for 1 of 4 residents (Resident #129) reviewed for Beneficiary Notices.

Inspectors wroteBased on observation, record review and staff interviews the facility failed to develop an individualized, person-centered comprehensive care plan to include the use of side rails (Resident #82 and Resident #119) and an anticoagulant (blood thinning) medication (Resident #129). This was for 3 of 27 residents whose comprehensive care plans were reviewed.

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to attempt to use alternatives prior to installing side rails for 2 of 3 residents (Resident #82 and Resident #119) reviewed for side rails.

Inspectors wroteBased on record review and staff interviews, the facility failed to obtain a baseline thyroid function test for a resident who was taking Levothyroxine Sodium for 1 of 5 residents reviewed for unnecessary medications (Resident #123).

Inspectors wroteBased on record review and interviews with the resident, Responsible Party (RP), and staff, the facility failed to facilitate the inclusion of a cognitively intact resident and her RP in the care planning process for 1 of 1 residents reviewed for the care planning process.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Preadmission Screening and Resident Review Level II (Resident #18) and oxygen therapy (Resident #41) for 2 of 26 residents reviewed for MDS accuracy.

Inspectors wroteBased on observation, record review, staff, family, and resident interview the facility failed to complete an assessment with wound measurements when a reopened wound was identified and to transcribe standing orders for wound care into the resident's treatment record to ensure the orders were implemented. This deficient practice was for 1 of 1 resident (Resident #29) reviewed for skin conditions.

Inspectors wroteBased on observations, record review, resident, staff and Medical Director interviews the facility failed to obtain a physician's order for the use of supplemental oxygen for 1 of 3 residents reviewed for respiratory care (Resident #101).

Inspectors wroteBased on observations, record review, and staff, family and resident interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification and complaint investigation surveys of 12/02/21 and 12/22/22. This was for two deficiencies in the areas of Accuracy of Assessments (F641) and Quality of Care (F684) that were subsequently recited on the current recertification and complaint investigation. The continued failure of the facility during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement their infection control policy when Nurse Aide (NA) #1 did not perform hand hygiene during meal delivery and set-up after handling bed linens and moving the overbed table for 1 of 2 NAs observed passing meal trays on 1 of 8 halls. This had the potential to result in the cross contamination of microorganisms between residents.