Emory L Bennett Memorial Veterans Nursing Home

Inspectors wroteBased on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's nourishment rooms, by failing to seal and date mark open food products in the nourishment rooms, clean residue build up in the ice machine drain hose and coffee dispenser hood, and clean in and around the ice machine dispenser ports and tray. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one resident (#2) who was visually impaired, from a total survey sample of 31 residents, received reasonable accommodation of needs for his call light. Failure to ensure that a resident who is visually impaired has the appropriate means to call for assistance can pose a safety risk to that resident.

Inspectors wroteBased on record review, interviews, and a review of the facility's policy and procedure, the facility failed to ensure that residents were properly screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, and that individuals identified with a MD or ID were evaluated and received care and services appropriate to their needs for one (Resident #48) of a total survey sample of 31 residents. Resident #48's Pre-admission Screening and Resident Review (PASRR) was incomplete with numerous areas of the form left blank. Incomplete PASRR forms can result in residents not receiving appropriate help/services and/or could create a delay in the process.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one (Resident #89) of a total survey sample of 31 residents, received care and services timely, in accordance with professional standards of practice, by failing to schedule physician-ordered magnetic resonance imaging (MRI). Failure to provide care timely poses a risk to residents' health due to delayed interventions.

Inspectors wroteBased on interviews and record review, the facility failed to provide food that accommodated resident preferences, by failing to provide options of similar nutritive value to residents who requested a different meal/snack choice for one (Resident #91) of four residents reviewed for nutrition, from a total survey sample of 31 residents. Resident #91, diagnosed with type 2 diabetes and blood sugar readings at times reaching 219 mg/dL, expressed a desire for sugar-free foods and snacks; however, they were not provided.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments. This failure involved the Delta 5 hallway medication cart, Delta 5 hallway treatment cart, Delta 3 hallway medication cart, Alpha 5 hallway treatment cart, Alpha 5 hallway medication cart, Alpha 3 hallway medication cart, and four separate nurses on two different shifts during three different days.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, and failed to provide adequate supervision for four (Residents #19, #25, #3, and #26) of four residents who smoked, kept their lighters in their rooms, and either used oxygen or were near oxygen concentrators. This practice endangered residents, staff and other building occupants.

Inspectors wroteBased on record review and interview, the facility failed to provide three (Residents #11, #18, and #36) of three samped residents, notices of non-coverage to allow residents the opportunity to make informed decisions about continued services and/or the right to an expedited review by a Quality Improvement Organization.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #39) of 21 residents receiving respiratory care, were provided such care per physician's orders.

Inspectors wroteBased on observations, interviews, medical record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #194) of seven residents requiring urinary catheter care, from a total sample of 27 residents.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide care and treatment in a timely manner, in accordance with professional standards of practice, the plan of care and the resident's choices for pain management and identifying a change of condition after a fall for 1 (#47) out of 4 residents sampled for accidents, from a total of 36 sampled residents. Resident #47 sustained a fracture of the hip and femur bones when he fell, but the first x-rays indicated no fractures. Three days later the resident requested transfer to the hospital due to extreme pain. Failure to manage pain and identify a change of condition after a fall negatively impacted Resident #47's ability to maintain his highest practicable, physical well being. [...]

Inspectors wroteBased on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff implemented the facility policy for the proper procedures for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen when staff failed to change gloves when they became contaminated, and to wash their hands between glove changes during the lunch meal service.

Inspectors wroteBased on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to ensure all essential kitchen equipment was maintained in safe operating condition by not ensuring proper maintenance of the mechanical, high temperature dishwashing machine and walk-in freezer.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to send notification to the Office of the State Long-term Care Ombudsman of resident transfers and discharges for two (Residents #5 and #75) of three residents sampled for a review of transfer and discharges, from a total sample of 36 residents.

Inspectors wroteBased on record review, staff interview and policy and procedure review, the facility failed to monitor resident behaviors and potential side effects related to the use of psychotropic medication for one (Resident #74) of five residents reviewed for unnecessary medications from a total of 36 residents in the sample.