Emanate Health Inter-Community Hospital- D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored under sanitary conditions by storing four one-gallon (liquid measurement) cartons of heavy cream in one of two walk-in refrigerators (Refrigerator 1) beyond the manufacturer's use-by date (the final date recommended by the maker for a consumer to use a product while it remains at peak quality, flavor, and texture) and as indicated in the facility's policy and procedure (P&P) titled, Food Supply and Storage Procedures. This deficient practice had the potential to result in foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages) to the residents consuming the food prepared with heavy cream.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure room temperatures were between 71 degrees Fahrenheit ( F - temperature scale) to 81 F for two of two sampled residents (Resident 7 and Resident 30). This deficient practice resulted in Resident 30 feeling cold and the potential for discomfort to Resident 7 and Resident 30 due to the room's temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dialysis emergency kit (a bag used to store emergency supplies) was kept at the bedside for one of one sampled resident (Resident 30), who was on dialysis (general term, a life-sustaining medical treatment that performs the essential functions of failing kidneys by filtering waste, toxins, and excess fluid from the blood) and as indicated in the facility's Policy and Procedure (P&P) titled Care of the Patient with an Arteriovenous Access. This deficient practice had the potential to result in delayed emergency services and excessive bleeding to Resident 30 during an accidental pull out of the arteriovenous access catheter (a soft, flexible tube inserted into a large vein in the neck, chest, or groin serving as a temporary lifeline to draw and return blood during hemodialysis).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was not 5 percent or greater. Two medication errors were identified out of 25 opportunities resulting in a medication error rate of eight percent. The facility failed to ensure medications were administered in accordance with physician orders for two of seven sampled residents (Resident 17 and Resident 26) by failing to:A. Ensure Novolog (Insulin Aspart - a rapid-acting type of insulin [one of many hormones that helps the body turn food into energy]) was administered with meals in accordance with the physician's order to Resident 17. B. Ensure Coreg (Carvedilol - a medication used to lower blood pressure) was administered with meals in accordance with the physician's order to Resident 26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to:a. Ensure staff followed Enhanced Barrier Precautions (EBP - extra measures, such as donning [putting on] a gown and gloves during high-contact care activities with residents who are at higher risk [have wounds] of having or spreading germs that are hard to treat) with Resident 27 during occupational therapy (OT - therapies used to increase independent function, and regain or build skills to perform every day activities).b. Ensure facility staff performed hand hygiene (HH) after patient care and prior to touching the curtains and blinds for Resident 30. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 11) had their urine collection bag fully covered. This deficient practice had the potential for Resident 11 to feel embarrassed and feel a loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 70) did not have more than three bed side rails while the bed was in the raised position. This deficient practice had the potential to result in Resident 70 to feel trapped in Resident 70's bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure ulcer/injury [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction [movement of one surface of the skin against the others]) prevention interventions were implemented for one of two sampled residents (Resident 10) to minimize the risk of developing PIs. Additionally, the facility failed to treat Resident 10's existing moisture associated skin damage (MASD) by failing to: a. Ensure Resident 10's heels were not touching the mattress b. Ensure Resident 10 was turned every two hours c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess the continued need for an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) and failed ensure a physician's order was obtained for the use of the device for 1 of five 5 sampled residents (Resident 121) upon admission from the intensive care unit (ICU, a special area in a hospital where patients receive very intensive care, including monitoring and treatment, for serious illnesses or injuries). Resident 121 remained with a urinary catheter for 2 days without a physician order indicating the medical necessity or indication in accordance with the facility's policy and procedure (P&P) titled, Catheterization, Urinary, #C-110. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to uphold its infection prevention and control program for 1 of 5 sampled residents (Resident 119) by failing to inform Resident 119's family Resident 119 was on Enhanced Barrier Precaution (EBP, an approach to use Personal Protective Equipment [PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection or illness] to reduce transmission of multi-drug-resistant organism), the purpose of the precautions, and the appropriate times and procedures for donning (putting on) gowns. This deficient practice had the potential to result in the transmission of infectious microorganisms and increased the risk of infection for Resident 119.

Inspectors wroteBased on interviews and record review, the facility failed to develop an individualized care plan (CP) and implement the CP to address the physical and psychosocial needs of four of four sampled residents (Residents 76, 16, 74, & 77) by failing to: A. Develop and implement a CP with interventions that addressed Resident 76's scrotal edema (swelling of the sac-like male reproductive structure). B. Develop and implement a CP with interventions that addressed Resident 16's alteration in nutrition. C. Develop and implement a CP with interventions that addressed Resident 74's uncontrolled diabetes mellitus (DM, metabolic disease involving inappropriately high blood sugar levels). D. Develop and implement a CP with interventions that addressed Resident 77's DM and insulin (hormone injected to treat DM) administration. [...]

Inspectors wroteBased on interviews and record review, the facility failed to accurately assess the fluid volume balance (balance between the amount of fluid entering and leaving the body) for one of one sampled resident (Resident 76), who had fluid restrictions ordered by the physician. The facility failed to accurately monitor and document Resident 76's intake and output (I&O, the amount of fluids that enter and leave the body) and the daily weight in accordance with the facility's policy and procedures (P&Ps). These failures had the potential cause a decline in Resident 76's physical and psychosocial well-being related to excess fluid in the body (fluid overload, condition in which the liquid portion of the blood [plasma] is too high causing signs such rapid weight gain, shortness of breath, high blood pressure, and swelling/edema on the arms, legs, face, and abdomen). (Cross Reference with F656)

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor a resident's weight and implement Calorie Count (monitoring and documenting resident consumption of meals for the purpose of estimating the total calories consumed) in accordance with the facility's policy and procedures (P&P) for one of one sampled resident (Resident 16). These failures had the potential to result in unmet nutritional needs due to a delay in the necessary interventions, which could lead to a physical decline to Resident 16. (Cross Reference with F656)

Inspectors wroteThe facility failed to ensure one of two residents (Resident 175) received dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) care consistent with facility policies by failing to assess Resident 175's atrioventricular shunt (AV shunt-a surgically created connection between vein and artery that allows direct access to the bloodstream for dialysis) every shift and take daily weights. This failure had the potential to cause a delay in care for Resident 175 and decline in overall health.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring of fluoxetine (trade name Prozac, a psychotropic [any drug that affected brain activities associated with mental processes and behavior] medication used to treat depression) for one of five sampled residents (Resident 77) by failing to provide documented evidence of any assessment of medication side effects/adverse effects (undesired harmful effect resulting from a medication) after multiple instances of Prozac administration. This failure had the potential to cause a decline in Resident 77's physical and/or psychosocial well-being due to possible unidentified adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed meet food safety requirements in one of one kitchen (Kitchen 1) when: a. There was a bag of leftover food observed in the patient nourishment refrigerator that was not dated or labeled with a 3-day expiration date and patient's name according to the facility's Policy and Procedure (P&P) titled, Food Brought into Patients from the Outside. b. There were trays of fresh eggs observed in the dairy and poultry refrigerator without labels indicating if the eggs were pasteurized (heated to destroy potential pathogens). These failures had the potential to result in residents to experience food-borne illnesses.

Inspectors wroteBased on interview and record review, the Medical Director (MD) failed to attend the quarterly Quality Assessment and Assurance (QAA) Committee meeting for three of three sampled meetings, according to the facility's Policy and Procedure (P&P) titled, Quality Assurance & Performance Improvement (QAPI) Program. This deficient practice had the potential to negatively affect the care delivered to the residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for two of six sampled residents (Residents 19 & 77), who had a peripheral intravenous (IV, into the vein) catheter, in accordance with the facility's policy and procedure (P&P) on IV Therapy Peripheral: Access and Care. a. Resident 19's peripheral IV site was observed undated/unlabeled on 5/13/2024. b. Resident 77's peripheral IV site was observed undated/unlabeled on 5/13/2024. These failures had the potential to result in an increased spread of infection in the facility. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provide preventive care by consistently turning residents every 2 hours on two of two sampled residents (Resident 41 and Resident 42). This failure had the potential to result in worsening of pressure injury (bed sore, injury to skin and underlying tissue resulting from prolonged pressure on skin) for Resident 41 and developing new pressure injury for Resident 42.