Hampden Post Acute

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections on two units (Unit B1 and Unit A2) out of three units and five Residents (#60, #121, #122, #15, and #5) out of a total sample of 24 residents. Specifically, the facility failed to ensure:On Unit B1, that facility staff adhered to the appropriate Personal Protective Equipment (PPE) protocols for removal of PPE for two Residents (#60 and #121) who were on Transmission-Based Precautions (TBP) for COVID/Influenza infections. [...]

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services that met professional standards of quality related to implementing Physician orders for medications and conducting assessments for one Resident's (#1) closed record out of three total closed resident records reviewed. Specifically, for Resident #1, the facility failed to ensure that:-Nurse #2 administered Physician ordered medications and completed vital signs and pain assessments as ordered when Nurse #2 held (not administered and not completed) Resident #1's medications and assessments on two shifts for two days with the Resident's consent not signed documented as the reason for holding care and services. -Nurse #2 reviewed and implemented Resident #1's admission agreement that included consent to admission and treatment, placing the Resident at risk for medical complications.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to maintain a medication administration error rate of less than five percent (%) when three medication errors were made out a total of 41 opportunities, resulting in a medication error rate of 7.32%. Specifically, for Resident #121, Nurse #4 failed to:1. ensure the correct medication dose was administered to the Resident, when Calcium 600 mg/ Vitamin D 200 units was ordered by the Physician and Calcium 600 milligrams (mg)/ Vitamin D [10 micrograms (mcg) = 400 units] was administered.2. ensure that the correct medication dose was administered when Vitamin B12 100 mcg was ordered by the Physician and Vitamin B12 500 mcg was administered.3. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure that one Resident (#69) of one applicable resident reviewed for dental services, out of a total sample of 24 residents, received routine dental services. Specifically for Resident #69, the facility failed to ensure that routine dental services were provided when dental consent for treatment was obtained and requested by the Resident and Resident Representative (RR) in June 2023, resulting in the Resident experiencing dental pain and discomfort.

Inspectors wroteBased on observations, and interviews, the facility failed to post nursing staff data daily, at the beginning of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift as required. Specifically, the facility failed to post nursing staff data that included the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse's Aides (CNAs).

Inspectors wroteBased on interview, record and policy review, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#73) out of a total sample of 20 residents. Specifically, for Resident #73, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #73's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself).

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#72) out of a total sample of 20 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #72.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to ensure an environment that was free from accidental hazards for one Resident (#16), out of a total sample of 20 residents. Specifically, the facility failed to provide a smoking apron for use during smoking activities for Resident #16 when the safety intervention was indicated in the Resident's comprehensive smoking assessment and care plans to ensure the Resident's safety related to smoking.

Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure that a gastrostomy tube (g-tube, a feeding tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication) care and management was provided in accordance with professional standards of practice for one Resident (#19) out of a total sample of 20 residents. Specifically, for Resident #19, the facility failed to: 1) obtain a Physician's order or care plan for g-tube replacement should it become dislodged. 2) replace the Resident's g-tube with a new g-tube after it was dislodged during a shower, to decrease the risk of contamination and infection to the Resident.

Inspectors wroteBased on observation, interview, facility assessment, record and policy review, the facility failed to ensure that the licensed nurses working in the facility had the specific competencies (measurable patterns of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) required to provide the care needed by the resident population for five Nurses (#1, #3, #4, #5 and #6) out of five applicable Nurses. Specifically, the facility failed to: 1. ensure that Nurse #1 had completed a competency for care and management of a gastrostomy tube (g-tube: [...]

Inspectors wroteBased on interview, record and policy review, the facility failed to offer the Influenza Vaccination as recommended for one Resident (#15) out of five applicable Residents, in a total sample of 20 Residents, putting the Resident at risk for developing infections. Specifically, the facility failed to ensure that Resident #15 was offered, received or declined the seasonal Influenza Vaccine during the 2023 through 2024 flu season.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care consistent with professional standards of practice to prevent a facility-acquired pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence which will often present as an open ulcer because of intense and/or prolonged pressure. Soft tissue damage related to pressure may also be affected by skin temperature and moisture) for one Resident (#65) out five applicable residents, in a total sample of 22 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the storage of medications and biologicals according to professional standards in two of three medication storage rooms, and three of six medication carts.

Inspectors wroteBased on record review and interviews, the facility failed to maintain complete and accurate medical records related to Physician's orders for three Residents (#23, #14, and #83) out of a total sample of 22 residents, and for three Residents (#89, #86, and #104) out of a sample of five residents for immunization review. Specifically, the facility failed to: 1. Ensure Physician's orders reflected the Residents' wishes related to Advanced Directives for three Residents (#23, #14, and #83). 2. Ensure a medication listed in the electronic medical record (EMR) accurately reflected the medication being administered to one Resident (#83). 3. Ensure the accuracy and completeness of immunization consents for three Residents (#89, #86, and #104).

Inspectors wroteBased on observation, record review and interview, the facility failed to follow professional standards relative to checking the placement of a gastrostomy tube (GTube/GT - a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) for one Resident (#86), out of two applicable residents, in a total sample of 22 residents. Specifically, the facility staff did not check the GT for placement as required, prior to administering Resident #86's medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to secure unattended medications on one out of three units. Specifically, unattended medications were left on the windowsill in a resident's room, to be accidentally ingested by another resident(s).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of care regarding respiratory equipment for two Residents (#55 and #362), out of a total sample of 22 Residents. Specifically, the facility staff failed to store respiratory equipment per policy to prevent contamination and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an as needed (PRN), pain medication upon request resulting in increased pain and discomfort for one Resident (#312), out of a total sample of 22 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide monitoring for adverse side effects of psychotropic medication (medication which affects mood and behavior) use and behaviors for two Residents (#22 and #90), out of a total sample of 22 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent during a medication administration pass. Two medication errors occurred for two Residents (#83 and #87), out of six Residents observed, in a total of 26 opportunities, resulting in a medication error rate of 7.69%.

Inspectors wroteBased on record review and interview, the facility failed to provide communication of Hospice services for one Resident (#99) out of a total sample of 22 residents. Specifically, the facility failed to ensure that its staff: -Designated an interdisciplinary team member to be responsible for collaborating with the Hospice Representative(s). -Maintained a record that contained the plan of care that included what individualized services the Hospice Agency would provide for the Resident.

Inspectors wroteBased on observation and interview, the facility staff failed to utilize infection control practices during the medication pass process for two out of six residents observed.